New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 370 - OVERSIGHT OF LICENSED HEALTHCARE FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS
Part 12 - REQUIREMENTS FOR ACUTE CARE, LIMITED SERVICES AND SPECIAL HOSPITALS
Section 8.370.12.24 - UTILIZATION MANAGEMENT
Universal Citation: 8 NM Admin Code 8.370.12.24
Current through Register Vol. 35, No. 18, September 24, 2024
A. Plan: Every hospital shall have in operation a written utilization management plan designed to ensure that quality patient care is provided in the most appropriate manner. The plan should address potential over and under utilization as well as the efficient use of resources for patients.
(1) Description of plan. T he written
utilization management plan shall include at a minimum at least the following:
(a) a delineation of the responsibilities and
authority of those involved in the performance of utilization management
activities, including utilization management personnel, administrative
personnel, and, when applicable, any qualified outside organization contracting
to perform review activities specified in the plan;
(b) a conflict of interest statement stating
that reviews may not be conducted by any person who has a proprietary interest
in any hospital or by any person who was professionally involved in the care of
the patient whose case is being reviewed;
(c) a confidentiality policy applicable to
all utilization management activities, including any findings and
recommendations;
(d) a description
of the process by which the hospital identifies and resolves utilization
related problems, including the appropriateness and medical necessity of
admissions, continued stays, and supportive services, as well as delays in the
provision of supportive services; and
(e) the following activities shall be
incorporated into the process: analysis of profiles and patterns of care,
feedback of results of profile analysis to the medical staff, documentation of
specific actions taken to correct aberrant practice patterns or other
utilization management problems, and evaluation of the effectiveness of action
taken.
(2) The plan must
include the procedures for conducting review, including the time period within
which the review is to be performed following admission and in assigning
continued stay review dates.
(3) A
mechanism for the provision of discharge planning as set forth under these
requirements must be included.
(4)
Responsibility for performance. The plan shall be approved by the medical
staff, administration and governing body. Hospital administration shall assure
the effective implementation of the plan.
B. Conduct of review.
(1) Written measurable criteria that have
been approved by the medical staff shall be utilized when performing
reviews.
(2) Nonphysician health
care professionals may participate in the development of review criteria and
conduct of review relative to services provided by their peers.
(3) Determinations regarding the medical
necessity and appropriateness of care provided shall be based upon information
documented in the medical record. The medical staff member primarily
responsible for the patient's care shall be notified whenever it is determined
that an admission or continued stay is not medically necessary, and shall be
afforded the opportunity to present his or her own views before a final
determination is made. At least two medical staff members shall make a
determination when the medical staff member primarily responsible for the
patient's care disagrees.
(4)
Different rules may apply to beneficiaries of, or enrollees in, plans which
provide medicare or medicaid services. If the hospital is a member of, or has a
contractual relationship with, a risk bearing entity, and such risk bearing
entity has a contract with CMS or with the New Mexico medicaid authority
(single state agency), then the applicable federal or state requirements shall
apply to enrollees under such a plan.
(5) Written notice of any decision that an
admission or continued stay is not medically necessary shall be given to the
appropriate hospital department, the medical staff member primarily responsible
for care of the patient and the patient no later than 72 hours after the
determination.
C. Records and reporting. Records shall be kept of hospital utilization management recommendations made to the medical staff and to the governing body as necessary. Recommendations relevant to hospital operations or administration shall be reported to administration.
Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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