§ 1163.92. Administrative sanctions.
(a) If the hospital utilization review committee fails to review a MA recipient’s need for admission or fails to request approval for the admission through the Department’s Bureau of Utilization Review, the Department denies payment for the hospital stay.
(b) For potential day outlier cases, if the Department determines that a day of care occurring any time during the period of hospitalization was not medically necessary, the Department excludes those days in determining entitlement to any outlier payment amount.
2(c) For potential cost outlier cases, if the Department determines that services or items provided by the hospital were not medically justified, or were unnecessary, inappropriate or otherwise noncompensable, the Department excludes the cost for those services as well as the cost of services and items related to the provision of that service in determining entitlement to and payment amount for an outlier payment.
(d) If the Department determines that a hospital bill for services inconsistent with this part, provided incorrect information on the billing invoice regarding a patient’s diagnosis or procedures performed during the period of hospitalization, the Department denies payment for the claims either concurrently or retroactively.
(e) If the Department determines that a hospital claim has been inappropriately coded based on information in the patient’s medical record or discovers coding errors, the Department corrects the claim for payment purposes.
(f) If the Department determines that a hospital’s utilization review process is not in accordance with the Department’s Manual for Diagnosis Related Group Review of Inpatient Hospital Services, the hospital shall take corrective action within the time specified by the Department.
(g) If the Department has requested that a hospital take corrective action on its utilization review process and the hospital fails to do so within the specified time, the Department will terminate the hospital’s provider agreement.
Source The provisions of this § 1163.92 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 (86846).
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