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 1163.80 - Adverse determinations

Universal Citation: 55 PA Code ยง 1163.80

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

(a) If the hospital utilization review committee denies admission or continued stay, the committee shall forward a letter regarding the adverse determination to:

(1) The recipient.

(2) The recipient's next of kin or sponsor, if applicable.

(3) The attending physician.

(4) The hospital administrator.

(5) The Office of MA, Bureau of Utilization Review.

(b) The adverse determination letter shall include:

(1) The patient's name.

(2) The patient's age.

(3) The patient's full MA number.

(4) The hospital's name.

(5) The admission date.

(6) The discharge date, if known.

(7) The diagnoses-required only on copy sent to the Office of MA.

(c) The hospital utilization review committee shall send the adverse determination letter no later than the day after the determination.

(d) Each month the hospital utilization review committee shall complete and submit to the Bureau of Utilization Review a summary report of adverse determinations in accordance with the instructions in the Provider Handbook. These instructions are also included in the Manual for Diagnosis Related Group Review of Inpatient Hospital Services.

(e) The hospital utilization review committee shall mail the monthly summary report specified in subsection (d) no later than 5 days after the end of the month.

This section cited in 55 Pa. Code § 1163.77 (relating to admission review requirements); and 55 Pa. Code § 1163.78a (relating to review requirements for day outliers).

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