Current through Register Vol. 54, No. 44, November 2, 2024
(a) Each enrolled nursing facility furnishing
services to eligible MA recipients shall have in effect a written Utilization
Review Plan that provides for review of each recipient's need for the
services.
(b) If the Utilization
Review Committee of a facility finds that the continued stay of a recipient at
a specific level of care is not needed, the committee shall request additional
information as follows:
(1) If the recipient
is receiving care in a skilled nursing facility, the committee shall request
additional information from the attending physician who shall respond within 7
days. Two physician members of the committee shall review the additional
information and make the final recommendation. If the attending physician does
not respond to the committee's request within 7 days, the committee's
recommendation shall be deemed final.
(2) If the recipient is receiving care in an
intermediate care facility, the committee shall, within 1 working day of its
decision, request additional information from the recipient's attending
physician, who shall respond within 2 working days. A physician member of the
committee, in cases involving a medical determination, or the Utilization
Review Committee, in cases not involving a medical determination, shall review
the additional information and make the final recommendation. If the attending
physician does not respond to the committee's request within 2 working days,
the committee's recommendation shall be deemed final.
(3) If the recipient is receiving care in an
intermediate care facility for the mentally retarded, the committee shall,
within 1 working day of its decision, request additional information from the
recipient's qualified mental retardation professional, who shall respond within
2 working days. A physician member of the committee, in cases involving a
medical determination, or the Utilization Review Committee, in cases not
involving a medical determination, shall review the additional information and
make the final recommendation. If the additional information is not received
within 2 working days, the committee's decision will be deemed
final.
(c) The
Utilization Review Committee will send written notice of any adverse final
decisions on the need for continued stay to:
(1) The nursing facility
administrator.
(2) The attending
physician of a recipient in a skilled nursing or intermediate care facility or
the qualified mental retardation professional of a recipient in an intermediate
care facility for the mentally retarded.
(3) The County Assistance Office.
(d) The County Assistance Office
will notify the recipient or the person acting on behalf of the recipient and
the facility of the recommended change in the level of care. The recipient has
the right of appeal in Chapter 275 (relating to appeal and fair hearing and
administrative disqualification hearings). Neither the facility nor the
attending physician may appeal the decision of the Utilization Review Committee
on their own behalf.
The provisions of this §1181.85 amended under sections
403(a) and (b) and 443.1(2) and (3) of the Public Welfare Code (62 P. S.
§§
403(a) and (b)
and 443.1(2) and (3)).
