§ 1163.475. Responsibilities of the hospital utilization review committee.
The hospital utilization review committee or its representative shall:
(1) Conduct admission reviews under § 1163.477 (relating to admission review requirements).
(2) Conduct continued stay reviews under § 1163.478 (relating to continued stay review requirements).
(3) Conduct Medical Care Evaluation studies under § 1163.479 (relating to Medical Care Evaluation studies).
(4) Notify the Department’s Concurrent Hospital Review Section of a recipient’s assigned initial or continued length of stay. This notification shall be done on the form specified and in accordance with the instructions in the Manual for Concurrent Hospital Review of Inpatient Services.
(5) Provide that the justification for a recipient’s need for admission and need for continued hospital inpatient services be documented by the attending physician in the recipient’s medical record.
(6) Notify the Department’s Concurrent Hospital Review Section of a change in a recipient’s diagnosis.
(7) Maintain utilization review records for a minimum of 4 years from the date of submission of the year end cost report.
(8) Submit copies of utilization review records and documents, medical records, certification of days records and discharge planning information to the Department upon request.
(9) Maintain copies of certification of days records with the patient’s medical record and with the hospital copy of the invoice submitted for payment.
(10) Review cases that the Department has identified as being of questionable utilization of hospital facilities or services or that contain noncompensable services or items as listed in § 1163.455 (relating to noncompensable services and items).
(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 Concurrent Hospital Review of Inpatient Services in conducting utilization review activities.
Source The provisions of this § 1163.475 adopted June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185.
Cross References This section cited in 55 Pa. Code § 1163.457 (relating to payment policies relating to out-of-State hospitals); and 55 Pa. Code § 1163.458 (relating to payment policies relating to same-calendar-day admissions and discharges).
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