Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1163 - INPATIENT HOSPITAL SERVICES
Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM
UTILIZATION CONTROL
Section 1163.75 - Responsibilities of the hospital utilization review committee

Universal Citation: 55 PA Code ยง 1163.75

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

The hospital utilization review committee or its representative shall:

(1) Conduct admission reviews under § 1163.77 (relating to admission review requirements).

(2) Conduct continued stay reviews for potential outliers under § 1163.78a (relating to review requirements for day outliers).

(3) Conduct Medical Care Evaluation studies under § 1163.79 (relating to Medical Care Evaluation studies).

(4) Conduct reviews for medical necessity of services for potential cost under § 1163.78b (relating to review requirements for cost outliers).

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

(i) An identification of the recipient.

(ii) Copies of the certification of admission document.

(iii) The name 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 initial and subsequent review dates specified under this chapter.

(vi) Documentation by the attending physician justifying the recipient's need for admission.

(vii) Documentation by the attending physician justifying the recipient's continued need for inpatient hospital services if requesting consideration as a day or cost outlier.

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

(6) Complete and submit a Hospital Admission DRG/CHR Certification Form for each MA recipient. If the form is not received by the Department within 10 calendar days of admission, payment for the inpatient services will be denied.

(7) Validate that the patient's diagnosis and other information specified in the patient's medical record conforms with the information on the invoice submitted for payment.

(8) Maintain utilization review records for a minimum of 4 years from the end of the fiscal year in which the recipient was discharged.

(9) Submit copies of utilization review records and documents, medical records, certification of admission document and discharge planning information to the Department upon request.

(10) Maintain copies of the certification of admission document with the patient's medical record and with the hospital copy of the invoice submitted for payment.

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

(12) Follow the procedures specified in the Department's Manual for Diagnosis Related Group Review of Inpatient Hospital Services in conducting utilization review activities.

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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