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 1163.78a - Review requirements for day outliers

(a) If a hospital intends to apply for an outlier payment on the basis of the hospital stay's qualifying as a day outlier, the hospital utilization review committee or its representative shall review the need for continued stay of the MA case.

(b) The hospital utilization review committee shall establish written criteria on which it bases a recipient's need for continued stay. The criteria shall be based on the recipient's medical condition and must be more extensive for those cases 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.

(c) The hospital utilization review committee or its representative shall assess the need for continued stay by comparing the case to the written criteria established under subsection (b).

(d) If a hospital stay qualifies as a day outlier under § 1163.56 (relating to outliers) the hospital utilization review committee or its representative shall assign subsequent review dates based on the date continued hospitalization will no longer be necessary.

(e) The hospital utilization review committee shall provide that the justification for the recipient's need for hospital inpatient services be documented in the patient's record.

(f) The hospital utilization review committee shall allow the attending physician the opportunity to present his views before making a final decision on the need for continued stay.

(g) In the event of an adverse determination, the hospital utilization review committee shall follow the procedures set forth in § 1163.80 (relating to adverse determinations).