§ 1163.481. Utilization review sanctions.
(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.
Authority 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)).
Source The provisions of this § 1163.481 adopted June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917. Immediately preceding text appears at serial page (150184).
Cross References 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).
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