55 Pa. Code § 1163.75 - Responsibilities of the hospital utilization review committee
The hospital utilization review committee or its representative shall:
(1) Conduct
admission reviews under §
1163.77 (relating to admission
review requirements).
(2) Conduct
continued stay reviews for potential outliers under §
1163.78a (relating to review
requirements for day outliers).
(3)
Conduct Medical Care Evaluation studies under §
1163.79 (relating to Medical Care
Evaluation studies).
(4) Conduct
reviews for medical necessity of services for potential cost under §
1163.78b (relating to review
requirements for cost outliers).
(5)
Provide that each recipient's record include:
(i) An identification of the
recipient.
(ii) Copies of the
certification of admission document.
(iii) The name of the recipient's
physician.
(iv) The date of
admission and date of application for and authorization of MA benefits if
application is made after admission.
(v) The initial and subsequent review dates
specified under this chapter.
(vi)
Documentation by the attending physician justifying the recipient's need for
admission.
(vii) Documentation by
the attending physician justifying the recipient's continued need for inpatient
hospital services if requesting consideration as a day or cost
outlier.
(viii) Other supporting
material the utilization review committee believes appropriate.
(6) Complete and submit a Hospital
Admission DRG/CHR Certification Form for each MA recipient. If the form is not
received by the Department within 10 calendar days of admission, payment for
the inpatient services will be denied.
(7) Validate that the patient's diagnosis and
other information specified in the patient's medical record conforms with the
information on the invoice submitted for payment.
(8) Maintain utilization review records for a
minimum of 4 years from the end of the fiscal year in which the recipient was
discharged.
(9) Submit copies of
utilization review records and documents, medical records, certification of
admission document and discharge planning information to the Department upon
request.
(10) Maintain copies of the
certification of admission document with the patient's medical record and with
the hospital copy of the invoice submitted for payment.
(11) Initiate discharge planning during the
admission review process to provide timely placement in an appropriate level of
care for those patients that may require posthospital care.
(12) Follow the procedures specified in the
Department's Manual for Diagnosis Related Group Review of Inpatient Hospital
Services in conducting utilization review activities.
Notes
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