§ 1151.76. Continued stay review requirements.
(a) The utilization review committee or its representative shall review the need for continued stay of each recipient admitted to the inpatient psychiatric facility.
(b) The utilization review committee shall establish written criteria on which it bases a recipient’s need for continued stay. The criteria shall be based on the recipient’s medical condition and 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 utilization review committee or its representative shall assess the need for continued stay in an inpatient psychiatric facility by comparing each case to the written criteria established under subsection (b).
(d) The utilization review committee or its representative shall assign subsequent review dates based on the date continued hospitalization will no longer be necessary.
(e) The utilization review committee or its representative shall conduct the continued stay review and provide the Department’s Concurrent Hospital Review Section with the medical justification for the continued stay on or before the expiration date of the initial length of stay. Subsequent reviews shall be completed before the expiration of the previously assigned length of stay.
(f) If an individual applies for MA while in an inpatient psychiatric facility, the committee shall:
(1) Assign the continued stay review date within 1 working day after the inpatient psychiatric facility is notified that the individual has applied for MA.
(2) Contact the Department’s Concurrent Hospital Review section for approval of the assigned length of stay.
(g) The utilization review committee shall provide that the justification for the recipient’s continued need for inpatient psychiatric services be documented in the patient’s record.
(h) The utilization review committee shall allow the attending physician the opportunity to present his views before making a final decision on the need for continued stay.
(i) In the event of an adverse determination, the utilization review committee shall follow § 1151.78 (relating to adverse determinations).
Authority The provisions of this § 1151.76 amended under sections 201 and 443.1(1) of the Public Welfare Code (62 P. S. § § 201 and 443.1(1)).
Source The provisions of this § 1151.76 adopted September 30, 1983, effective July 1, 1983, 13 Pa.B. 2796; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917. Immediately preceding text appears at serial pages (150078) to (150079).
Cross References This section cited in 55 Pa. Code § 1151.61 (relating to payment conditions: general); 55 Pa. Code § 1151.67 (relating to payment conditions related to the recipient’s continued need for care); 55 Pa. Code § 1151.72 (relating to inpatient psychiatric facility utilization review plan); 55 Pa. Code § 1151.74 (relating to responsibilities of the inpatient psychiatric facility utilization review committee); and 55 Pa. Code § 1151.75 (relating to admission review requirements).
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