§ 1163.477. Admission review requirements.
(a) The hospital utilization review committee or its representative shall review the need for admission of each MA recipient admitted to the hospital within 24 hours after admission. The committee shall make a final determination of the need for admission within 2 working days after admission, unless the case or category of admission is designated for preadmission review.
(b) The hospital utilization review committee shall establish written criteria on which it bases a recipient’s need for admission. The criteria shall be more extensive for admissions known to be associated with high costs, associated with the frequent furnishing of excessive services or authorized by a physician whose patterns of care are questionable.
(c) The hospital utilization review committee shall assess the need for hospital inpatient services by comparing each admission to the hospital’s written criteria established in accordance with subsection (b).
(d) Except as noted in subsection (e), an initial length of stay for general hospitals must be no greater than the 50th percentile of the latest Hospital Utilization Project (HUP) length of stay guidelines per diagnosis category, per age group. Ten days will be assigned as the initial length of stay for rehabilitation hospitals when the HUP 50th percentile for the admitting diagnosis is 10 days or less with the actual HUP 50th percentile used to assign the initial length of stay for other admissions. The HUP length of stay guidelines appear in the HUP Length of Stay Manual designated by the Department, and are statistical tables reflecting the length of stay of inpatient hospital stays in the Mid-Atlantic Region of the United States.
(e) If a recipient’s diagnosis is unconfirmed upon admission, the hospital utilization review committee, or its representative, shall assign an initial length of stay of no more than 2 days. If the committee is unable to confirm the recipient’s diagnosis within 2 days, the committee shall notify the Department’s Concurrent Hospital Review unit and initiate continued stay review in accordance with § 1163.478 (relating to continued stay review requirements).
(f) The hospital utilization review committee shall allow the attending physician the opportunity to present his views before making a final decision on the need for admission.
(g) In the event of an adverse determination, the hospital utilization review committee shall follow the procedures in § 1163.480 (relating to adverse determinations).
(h) The hospital utilization review committee shall conduct a review of cases identified by the Office of MA Programs, as being a questionable utilization of hospital services and facilities.
Authority The provisions of this § 1163.477 amended under sections 201 and 443.1(1) of the act of June 13, 1967 (P. L. 31, No. 21) (62 P. S. § § 201 and 443.1(1)).
Source The provisions of this § 1163.477 adopted June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917. Immediately preceding text appears at serial pages (150179) to (150181).
Cross References This section cited in 55 Pa. Code § 1163.457 (relating to payment policies relating to out-of-State hospitals); 55 Pa. Code § 1163.458 (relating to payment policies relating to same-calendar-day admissions and discharges); 55 Pa. Code § 1163.473 (relating to hospital utilization review plan); and 55 Pa. Code § 1163.475 (relating to responsibilities of the hospital utilization review committee).
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