§ 1181.85. Facility utilization review requirements.
(a) Each enrolled nursing facility furnishing services to eligible MA recipients shall have in effect a written Utilization Review Plan that provides for review of each recipient’s need for the services.
(b) If the Utilization Review Committee of a facility finds that the continued stay of a recipient at a specific level of care is not needed, the committee shall request additional information as follows:
(1) If the recipient is receiving care in a skilled nursing facility, the committee shall request additional information from the attending physician who shall respond within 7 days. Two physician members of the committee shall review the additional information and make the final recommendation. If the attending physician does not respond to the committee’s request within 7 days, the committee’s recommendation shall be deemed final.
(2) If the recipient is receiving care in an intermediate care facility, the committee shall, within 1 working day of its decision, request additional information from the recipient’s attending physician, who shall respond within 2 working days. A physician member of the committee, in cases involving a medical determination, or the Utilization Review Committee, in cases not involving a medical determination, shall review the additional information and make the final recommendation. If the attending physician does not respond to the committee’s request within 2 working days, the committee’s recommendation shall be deemed final.
(3) If the recipient is receiving care in an intermediate care facility for the mentally retarded, the committee shall, within 1 working day of its decision, request additional information from the recipient’s qualified mental retardation professional, who shall respond within 2 working days. A physician member of the committee, in cases involving a medical determination, or the Utilization Review Committee, in cases not involving a medical determination, shall review the additional information and make the final recommendation. If the additional information is not received within 2 working days, the committee’s decision will be deemed final.
(c) The Utilization Review Committee will send written notice of any adverse final decisions on the need for continued stay to:
(1) The nursing facility administrator.
(2) The attending physician of a recipient in a skilled nursing or intermediate care facility or the qualified mental retardation professional of a recipient in an intermediate care facility for the mentally retarded.
(3) The County Assistance Office.
(d) The County Assistance Office will notify the recipient or the person acting on behalf of the recipient and the facility of the recommended change in the level of care. The recipient has the right of appeal in Chapter 275 (relating to appeal and fair hearing and administrative disqualification hearings). Neither the facility nor the attending physician may appeal the decision of the Utilization Review Committee on their own behalf.
Authority The provisions of this § 1181.85 amended under sections 403(a) and (b) and 443.1(2) and (3) of the Public Welfare Code (62 P. S. § § 403(a) and (b) and 443.1(2) and (3)).
Source The provisions of this § 1181.85 codified July 24, 1981, effective July 25, 1981, 11 Pa.B. 2610; amended January 7, 1983, effective January 8, 1983, 13 Pa.B. 148. Immediately preceding text appears at serial page (62950).
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