Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES
UTILIZATION CONTROL
Section 1151.75 - Admission review requirements
Current through Register Vol. 54, No. 12, March 23, 2024
(a) The utilization review committee or its representative shall review the need for admission of each recipient admitted to the inpatient psychiatric facility within 24 hours of the admission.
(b) The utilization review committee or its representative shall make a final determination of each recipient's need for admission within 2 working days after the admission.
(c) The utilization review committee shall establish written criteria on which it bases a recipient's need for admission. The criteria shall be more extensive for admissions known to be associated with high costs, associated with the frequent furnishing of excessive services, or authorized by a physician whose patterns of care are questionable.
(d) The utilization review committee or its representative shall assess the need for inpatient psychiatric services by comparing each admission to the written criteria established in accordance with subsection (c).
(e) Except as noted in subsection (f), the utilization review committee or its representative shall use the Hospital Utilization Project (HUP) 50th percentile length of stay guidelines in assigning an initial length of stay.
(f) If a recipient's diagnosis is unconfirmed upon admission, the utilization review committee or its representative shall assign an initial length of stay of no more than 2 days. If the utilization review committee is unable to confirm the recipient's diagnosis within 2 working days, the committee shall notify the Department's Concurrent Hospital Review Section and initiate continued stay review in accordance with § 1151.76 (relating to continued stay review requirements).
(g) The utilization review committee shall allow the attending physician the opportunity to present his views before making a final decision on the need for admission.
(h) In the event of an adverse determination, the utilization review committee shall follow the procedures set forth in § 1151.78 (relating to adverse determinations).
(i) The utilization review committee shall conduct a review of cases identified by the Department as being a questionable utilization of inpatient psychiatric services and facilities.
The provisions of this § 1151.75 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); 55 Pa. Code § 1151.67 (relating to payment conditions related to the recipient's continued need for care); 55 Pa. Code § 1151.72 (relating to inpatient psychiatric facility utilization review plan); and 55 Pa. Code § 1151.74 (relating to responsibilities of the inpatient psychiatric facility utilization review committee).
