Md. Code Regs. 10.07.01.13 - Utilization Review Plan
A. Before
October 1, 1985, each hospital shall submit a proposed utilization review plan
to the Secretary.
B. Effective
October 1, 1985, each hospital shall have in effect a utilization review plan
approved by the Secretary pursuant to this chapter.
C. The purpose of the hospital's utilization
review program, as defined by the plan, shall be to determine for patients
included in the hospital's review responsibilities the:
(1) Reasonableness and medical necessity of
care given or proposed to be given at the hospital;
(2) Quality of care given at the hospital;
and
(3) Appropriateness of the
level of care proposed or given, including whether the care could be or could
have been provided appropriately and more economically on an outpatient basis
or in a facility that provides a lower level of care.
D. A utilization review plan shall:
(1) Identify the designated utilization
review agent;
(2) Describe the
criteria to be used in evaluating proposed or delivered hospital
care;
(3) Delineate the types and
kinds of cases that the agent will review and the circumstances under which
either some or all patients in the hospital, or within specific diagnostic
groups, will be selected;
(4) Make
provisions for the collecting, storing, and reporting of data;
(5) Define measures by which the agent can
evaluate the effectiveness of its program;
(6) Make provisions for screening medical
records pertaining to patients for which the agent has review responsibility in
order to identify and verify problems in the quality of care;
(7) Establish a mechanism through which
patients, physicians, or third-party payers may seek reconsideration of
decisions made by the utilization review agent;
(8) Detail how each of the following elements
is to be performed by the agent:
(a)
Pre-admission review of elective admissions;
(b) Post-admission review of nonelective
admissions;
(c) Concurrent or
retrospective review of admissions;
(d) Pre-authorization of certain selected
procedures proposed to be performed on an inpatient basis;
(e) Institution of an objective second
surgical opinion protocol to evaluate the desirability of performing selected
surgical procedures on an elective basis;
(f) Discharge planning review;
(g) Continued stay review; and
(h) Re-admission review;
(9) Meet all other requirements for
utilization review promulgated by the Secretary.
Notes
Regulation .13 amended effective May 23, 1994 (21:10 Md. R. 844)
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