§ 1163.77. 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. Transfers and readmissions are considered new hospital admissions for utilization review purposes.
(b) The hospital utilization review committee shall make a final determination of the need for admission within 2 working days after admission, unless the case has been designated for preadmission review in accordance with the Department’s Manual for Diagnosis Related Group Review of Inpatient Hospital Services.
(c) If the recipient is readmitted to the hospital within 7 days of discharge, the admission review shall include a review of the patient’s previous admission to determine if:
(1) The readmission is for the provision of services that could or should have been provided during the previous admission.
(2) The readmission is the result of complications of the conditions that led to the previous admission.
(3) The readmission is unrelated to the previous admission.
(d) If an individual applies for MA while in the hospital, the committee or its representative shall:
(1) Review the need for hospitalization within 1 working day after the hospital is notified that the individual has applied for MA.
(2) Submit a Hospital Admission DRG/CHR Certification Form for the individual in accordance with the instructions set forth in the Department’s Manual for Diagnosis Related Group Review of Inpatient Hospital Services.
(e) The hospital utilization review committee or its representative shall make a final determination of each recipient’s need for admission no later than 2 working days after the admission.
(f) 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 those 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.
(g) The hospital utilization review committee or its representative shall assess the need for hospital inpatient services by comparing each admission to the hospital’s written criteria established under subsection (f).
(h) 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.
(i) In the event of an adverse determination, the hospital utilization review committee shall follow the procedures set forth in § 1163.80 (relating to adverse determinations).
(j) The hospital utilization review committee shall conduct a review of those cases identified by the Office of MA, Bureau of Utilization Review as being a questionable utilization of hospital services and facilities.
Source The provisions of this § 1163.77 adopted September 23, 1983, effective September 24, 1983, 13 Pa.B. 2881; amended June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185. Immediately preceding text appears at serial pages (85057) to (85058).
Cross References This section cited in 55 Pa. Code § 1163.73 (relating to hospital utilization review plan); and 55 Pa. Code § 1163.75 (relating to responsibilities of the hospital utilization review committee).
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