55 Pa. Code § 1151.78. Adverse determinations.

§ 1151.78. Adverse determinations.

(a)  The utilization review committee shall send an adverse determination letter on each case for which it denies admission or denies continued stay. The letter shall be sent to:
   (1)  The recipient.
   (2)  The recipient’s next of kin or sponsor, if applicable.
   (3)  The attending physician.
   (4)  The inpatient psychiatric facility administrator.
   (5)  The Office of MA Programs.
(b)  The adverse determination letter shall include:
   (1)  The recipient’s name.
   (2)  The recipient’s age.
   (3)  The recipient’s full MA number.
   (4)  The inpatient psychiatric facility’s name.
   (5)  The admission date.
   (6)  The discharge date, if known.
   (7)  The diagnoses required only on copy sent to the Office of MA Programs.
(c)  The utilization review committee shall send the adverse determination letter no later than by the last day of the approved length of stay or the day after the determination, whichever is earlier.
(d)  If a continued stay has been denied, the inpatient psychiatric facility shall attach a copy of the adverse determination letter to the invoice submitted for payment.
(e)  Each month the utilization review committee shall complete and submit a summary report of adverse determinations in accordance with the instructions in the Department’s Manual for Concurrent Review of Inpatient Hospital Services.
(f)  The utilization review committee shall mail the monthly summary report specified in subsection (e) within 15 days after the end of the month.

Authority

   The provisions of this §  1151.78 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 §  1151.78 adopted September 30, 1983, effective July 1, 1983, 13 Pa.B. 2796; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917; amended October 29, 1993, effective July 1, 1993, 23 Pa.B. 5241. Immediately preceding text appears at serial pages (181812) to (181813).

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 §  1151.75 (relating to admission review requirements); and 55 Pa. Code §  1151.76 (relating to continued stay review requirements).

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