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 1163.78b - Review requirements for cost outliers

Universal Citation: 55 PA Code ยง 1163.78b

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

(a) If a hospital intends to apply for an outlier payment on the basis of the hospital stay's qualifying as a cost outlier, the hospital utilization review committee or its representative shall review the services provided to the recipient to determine medical necessity.

(b) The utilization review committee or its representative shall identify services provided to the recipient listed as noncompensable services and items and services provided during noncompensable outlier days as specified under § 1163.59 (relating to noncompensable services, items and outlier days).

This section cited in 55 Pa. Code § 1163.73 (relating to hospital utilization review plan); and 55 Pa. Code § 1163.75 (relating to responsibilities of the hospital utilization review committee).

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