Current through Bulletin 2024-06, March 15, 2024
The Hospital Utilization Review Program is administered and
operated in accordance with Title 63A, Chapter 13.
(1) The purpose of the hospital utilization
review program is to ensure:
(a) efficient
and effective delivery of services;
(b) services are appropriate and medically
necessary;
(c) service quality is
maintained; and
(d) the State
satisfies federal requirements for a statewide surveillance and utilization
control program.
(2) The
Hospital Utilization Review Program shall conduct assessments and audits to
ensure the appropriateness and medical necessity of the following:
(a) Admissions to a hospital or a designated
distinct part unit within a hospital;
(b) Transfers from one acute care hospital to
another acute care hospital, or to an inpatient rehabilitation hospital or
psychiatric unit in another acute care hospital (inter-facility
transfer);
(c) Transfers from an
acute care setting to an inpatient rehabilitation unit of a hospital or
psychiatric unit within the same facility (intra-facility transfer);
(d) Continued stays;
(e) Services, surgical services and
diagnostic procedures;
(f)
Principal diagnosis, principal surgical procedure or both, reflected on paid
claims to ensure consistency with the attending physician's determination and
documentation as found in the member's medical record;
(g) Determine whether co-morbidity, as found
on the claim, is correct and consistent with the attending physician's
determination and compatible with documentation found in the member's medical
record; and
(h) Quality of
care.
(3) The Hospital
Utilization Review Program shall conduct assessments and audits to determine:
(a) Appropriate utilization;
(b) Compliance with state and federal
Medicaid regulations;
(c) Whether
documentation meets state and federal requirements for sufficiency, and whether
it accurately describes the status of services provided to the member;
and
(d) Whether procedures that
require prior authorization have been approved before the provision of
services, except in cases that meet the criteria listed in the Utah Medicaid
Section 1: General Information Provider Manual (Retroactive
Authorization).
(4) The
Hospital Utilization Review Program shall make determinations of medical
necessity, appropriateness of care, and suitability of discharge planning in
accordance with the following criteria and protocols:
(a) InterQual Criteria;
(b) Administrative rules or criteria
developed by Medicaid for programs and services not otherwise addressed;
and
(c) DRGs.
(5) Hospital Utilization Readmission Policy
and Reviews.
(a) Whenever information
available to the reviewer indicates the possibility of readmission to acute
care within 30 days of the previous discharge, the staff administering and
operating the Hospital Utilization Review Program may review any claim for:
(i) Readmission for the same or a similar
diagnosis to the same hospital, or to a different hospital;
(ii) Appropriateness of inter-facility
transfers; and
(iii)
Appropriateness of intra-facility transfers.
(b) The Hospital Utilization Review Program
shall review all suspected readmissions within 30 days of a previous discharge
to ensure that Medicaid criteria have been met for severity of illness,
intensity of service, and appropriate discharge planning and financial impact
to the Department as noted in Subsection R414-2A-10(3).
(c) If a member is readmitted for the same or
similar diagnosis within 30 days of discharge and, if after review as described
in Subsection R414-2A-10(5)(b), program review staff determines that
readmission does not meet the criteria in Subsection R414-2A-10(3)(b), then the
payment shall be combined into a single DRG payment, unless it is cost
effective to pay for two separate admissions. The first DRG (initial admission)
shall be the DRG that is paid. This policy does not apply to cases related to
pregnancy, neonatal jaundice, or chemotherapy.
(6) Definition, Policy Application.
(a) When applying policy, a similar diagnosis
is defined as:
(i) Any diagnoses code with
similar descriptors;
(ii) Any
exchange or combination of principal and secondary diagnosis; and
(iii) Any other sets of principal diagnoses
established to be similar by Utah Medicaid policy in written criteria and
published to the hospitals prior to service dates.
(b) The evaluation criteria for utilization
control are severity of illness, intensity of service, and cost effectiveness
as noted in Subsection R414-2A-10(5)(b).
(7) Appropriate remedial action will be
initiated for inappropriate readmissions when identified though the hospital
utilization post-payment review process.
(8) Applicability to Outpatient Hospital
Services.
(a) When a Medicaid member is
readmitted to the hospital, or readmitted as an outpatient within 30 days of a
previous discharge for the same or similar diagnosis, Medicaid will evaluate
both claims to determine if they should be combined into a single payment or
paid separately.
(9)
Recovery of Funds.
(a) The Department shall
recover payment when post-payment review finds that services are not medically
necessary, not appropriate, or that quality of service is not
suitable.
(b) The Department shall
recover payment when it determines there is a violation of the 30-day
re-admission policy.
(10) Hospital Utilization Review.
(a) Each month, the Hospital Utilization
Review Program shall review at least 5 percent of a selected universe of claims
adjudicated in the previous month. At least 2.5 percent of the claims shall be
a random sample. Up to 2.5 percent may be a focused review on a specific
service. A staff decision to focus on a specific service shall be made no later
than the beginning of the sample cycle.
(b) The Department shall select the universe
from paid inpatient hospital claims within the Data Warehouse. The universe
from which the random sample is selected is defined as all inpatient hospital
claims adjudicated before the beginning of the review cycle, except for:
(i) Claims showing, as a principal diagnosis,
any International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM) delivery code in the ICD-10-CM Manual Chapter 15 --
Pregnancy, Childbirth, and the Puerperium, in the range of O00 through O9A.53,
and other ICD-10-CM codes or DRG or DRGs as specified by policy or
administrative decision.
(ii)
Claims that show $0 payment by Medicaid;
(iii) Medicare crossover claims;
(iv) Claims with other codes or diagnoses
determined by the review program staff to be inappropriate for
review.
(c) The sample
cycle shall begin on the first working day of each month.
(11) Utah State Hospital Utilization Review.
(a) The purpose of this utilization review is
to ensure that Medicaid funds, as defined under 42 CFR 456, Subpart D, are
expended appropriately and to ensure that services provided to Medicaid members
at the Utah State Hospital (USH) are necessary and of high quality. Review
program staff shall conduct oversight activities at USH.
(b) Oversight activities include quarterly
clinical utilization reviews in which program staff review a sample of members
who are under 21 years of age and are 65 years of age or older, and who were
reviewed by USH utilization review staff during a previous quarter. These
reviews are performed to:
(i) Evaluate the
USH utilization process; and
(ii)
Address the clinical topic selected for that quarter's review.
(c) Reviews of USH Quality
Improvement and Quality Assurance programs are conducted to determine whether:
(i) The programs have been implemented in
accordance with written hospital policy;
(ii) The programs are effective in meeting
stated goals;
(iii) Improvements or
modifications have been made to increase the effectiveness of program
design.
(12)
Applicability to Inpatient Psychiatric Care and Inpatient Rehabilitation
Services.
(a) Provisions in the Hospital
Utilization Review Program also apply to inpatient psychiatric care and
inpatient rehabilitation services.