§ 1163.72. Utilization review: general.
(a) Each hospital shall conduct reviews of each MA recipient’s need for admission for inpatient hospital services and short procedure unit services in accordance with the Department’s Manual for Diagnosis Related Group Review of Inpatient Hospital Services.
(b) The Department’s Bureau of Utilization Review regularly monitors each hospital’s utilization review program to determine whether or not it is operating in accordance with the utilization review process and the MA regulations in this part. Monitoring is carried out through review of the hospital’s admissions, readmissions, transfers, outliers, patient records, physicians’ practice patterns and paid claims.
(c) The Department approves or disapproves the recipient’s need for admission or readmission through its utilization review process.
(d) If a discrepancy exists between a hospital’s utilization review plan and the instructions set forth in the Department’s Manual for Diagnosis Related Group Review of Inpatient Hospital Services, the Department’s manual takes precedence.
(e) If the Department requests additional information on an admission or a day or cost outlier, the hospital shall submit the information within 30 calendar days of the request. If the hospital does not submit the requested information within 30 calendar days, the Department will make a decision based on the available information.
(f) Unless additional information is requested, the Department approves or disapproves the admission of each MA recipient within 5 days of receipt of the Hospital Admission DRG/CHR Certification Form.
(g) If the Department requests additional information for a hospital admission, the Department will notify the hospital of the approval or disapproval within 30 days of receipt of the additional information.
Source The provisions of this § 1163.72 adopted September 23, 1983, effective September 24, 1983, 13 Pa.B. 2881; amended June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185. Immediately preceding text appears at serial page (85054).
Notes of Decisions This section supports the Department’s decision to deny reimbursement to a hospital which admitted patient overnight for treatment which could have safely been rendered in Special Procedure Unit. Episcopal Hospital v. Department of Public Welfare, 528 A.2d 676 (Pa. Cmwlth. 1987).
Cross References This section cited in 55 Pa. Code § 1126.71 (relating to scope of utilization review process).
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