Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES
UTILIZATION CONTROL
Section 1151.74 - Responsibilities of the inpatient psychiatric facility utilization review committee

Universal Citation: 55 PA Code ยง 1151.74

Current through Register Vol. 54, No. 44, November 2, 2024

The utilization review committee, or its representative, shall:

(1) Conduct admission reviews in accordance with § 1151.75 (relating to admission review requirements).

(2) Conduct continued stay reviews in accordance with § 1151.76 (relating to continued stay review requirements).

(3) Conduct medical care evaluation studies in accordance with § 1151.77 (relating to medical care evaluation studies).

(4) Notify the Department's Concurrent Hospital Review Section of a recipient's assigned initial or continued length of stay. This notification shall be done on the form specified and in accordance with the instructions in the Manual for Concurrent Review of Inpatient Hospital Services.

(5) Provide that each recipient's record include:

(i) Identification of the recipient.

(ii) Copies of the certification of days records.

(iii) The names of the recipient's physician.

(iv) The date of admission and date of application for and authorization of MA benefits if application is made after admission.

(v) The plan of care required under § 1151.65 (relating to plan of care).

(vi) Initial and subsequent review dates specified in accordance with this chapter.

(vii) Justification of the recipient's need for admission and need for continued inpatient hospital services as documented by the attending physician.

(viii) The reasons and plan for continued stay, if the physician believes continued stay is necessary.

(ix) Other supporting material the utilization review committee believes appropriate.

(6) Notify the Department's Concurrent Hospital Review Section of a change in a recipient's diagnosis.

(7) Maintain utilization review records for a minimum of 4 years from the date of submission of that year end cost report.

(8) Submit copies of utilization review records and documents, medical records, psychiatric and social evaluation records, certification of days records and discharge planning information to the Department upon request.

(9) Maintain copies of certification of days records with the patient's medical record and with the hospital copy of the invoice submitted for payment.

(10) Review cases that the Department identifies as being a questionable utilization of inpatient psychiatric facilities or services or that contain noncompensable services or items as listed in § 1151.48 (relating to noncompensable services and items).

(11) Initiate discharge planning during the admission review process to provide timely placement in an appropriate level of care for patients that may require posthospital care.

The provisions of this §1151.74 amended under sections 201 and 443.1(1) of the Public Welfare Code (62 P. S. §§ 201 and 443.1(1)).

This section cited in 55 Pa. Code § 1151.61 (relating to payment conditions: general); and 55 Pa. Code § 1151.67 (relating to payment conditions related to the recipient's continued need for care).

Disclaimer: These regulations may not be the most recent version. Pennsylvania 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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