Md. Code Regs. 10.07.01.15 - Performance Standards for Utilization Review
The hospital's program shall apply to all patients with the exceptions of those noted in Regulation .17, below. Except when noted for certain types of review, the program may delineate certain types and kinds of cases to be reviewed, so as to most efficiently carry out the purposes of these regulations. As a minimum, the hospital utilization review program shall satisfy the following performance standards:
A. Pre-admission Review.
(1) A review of those elective admissions
identified under the plan shall be performed by the agent in advance of the
proposed admission.
(2) The purpose
of this review shall be to determine the reasonableness and medical necessity
of the admission, and the appropriateness of the level of proposed
care.
(3) In conducting the review,
the agent may supplement the information provided by the hospital through
discussion with the patient's physician.
(4) The agent, using specific medical
criteria, shall render a decision as to whether the admission is medically
appropriate within 3 working days of the time it receives the case, except in
those circumstances when responding within this period would not permit
sufficient consultation or discussion to render a responsible
opinion.
B.
Post-admission Review.
(1) For those
categories of emergency admissions identified for review in the hospital's
plan, the agent shall carry out a review to ascertain the:
(a) Reasonableness and medical necessity of
the admission;
(b) Appropriateness
of the level of care provided; and
(c) Justification for the non-elective nature
of the admission.
(2)
The agent shall be notified by the hospital within 24 working hours of the
admission and the agent shall carry out the review within 3 working days of
notification, except in cases when appropriate consultation cannot be carried
out in this period of time.
C. Concurrent or Retrospective Review.
(1) For patients included in the plan the
agent shall determine whether each day of the patient's hospitalization was
medically necessary and appropriate based upon nationally recognized criteria.
The agent shall also designate those days of hospitalization caused by
administrative requirements including days on which patients await appropriate
placement or equipment needed after discharge.
(2) The review may be concurrent with the
patient's stay or take place after the patient is discharged.
(3) Days designated as administrative shall
be found appropriate only if approved under discharge planning review, as
discussed in §F.
D.
Pre-authorization Review.
(1) The agent shall
review prospectively all elective admissions in which one or more of the plan
designated procedures is the principal procedure being performed for that
admission.
(2) The procedures for
which pre-authorization is required are set forth in Regulation .21.
(3) The agent may approve inpatient treatment
for the listed procedures only if there is documentation that equivalent
outpatient treatment would not be medically appropriate for the
patient.
(4) All non-elective
admissions that have not been pre-authorized and that subsequently involve
performance of one or more of the plan designated procedures shall be reviewed
concurrently or retrospectively by the agent.
E. Objective Second Opinion.
(1) Before an elective admission for a
surgical procedure designated below, the patient shall obtain an objective
second opinion.
(2) The procedures
for which a second opinion is required are set forth in Regulation
.22.
(3) The second opinion may be
rendered by any physician of the patient's choosing except a physician having
any financial relationship with the patient's original physician.
(4) Should a voluntary admission not take
place within 6 months of the rendering of the second opinion, then another
opinion shall be sought before admission.
(5) The agent may waive the requirement for
obtaining a second opinion because:
(a)
Obtaining the second opinion would impose a hardship on the patient;
or
(b) The patient's medical
insurance does not cover second opinions, and was:
(i) Issued and delivered in another state,
and
(ii) Not intended to cover
persons living or working in Maryland.
F. Discharge Planning.
(1) The utilization review plan shall set
forth the hospital's discharge planning procedures.
(2) The agent shall review the effectiveness
of the hospital's discharge planning.
(3) The agent shall review those days of care
which have been designated to be administrative as a result of the agent's
concurrent or retrospective review.
(4) Administrative days may be approved as
necessary and appropriate only if evidence can be found that the hospital has
developed and implemented a discharge plan at the earliest possible time and
there is evidence that appropriate placement efforts have been made.
G. Continued Stay Review. For
patients in beds licensed for long term care, the agent shall periodically
review and certify as appropriate the level of care and placement, and the
medical necessity of treatment prescribed.
H. Re-admission Review. The agent shall
review the appropriateness of the previous discharge and the indications for
admission for hospitalizations occurring shortly after a previous
discharge.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.