Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1163 - INPATIENT HOSPITAL SERVICES
Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES
UTILIZATION CONTROL
Section 1163.481 - Utilization review sanctions
Current through Register Vol. 54, No. 44, November 2, 2024
(a) The Office of MA Programs regularly monitors each hospitals utilization review program to determine whether or not it is operating under the Concurrent Hospital Review process and this part. Monitoring is carried out through review of admissions, continued stays, patient records and claims paid by the Department.
(b) If the Department identifies delays in assigning the initial or continued length of stay, the Department will deny payment for all or part of the hospital stay.
(c) If the Department determines that services or items provided by the hospital were not medically justified, or were unnecessary, inappropriate or noncompensable, the Department will deny payment for the service or item and for services related to the provision of that service or item. Payment will also be denied to the practitioner who ordered the service.
The provisions of this §1163.481 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 § 1163.457 (relating to payment policies relating to out-of-State hospitals); and 55 Pa. Code § 1163.458 (relating to payment policies relating to same-calendar-day admissions and discharges).
