§ 1163.478. Continued stay review requirements.
(a) The hospital utilization review committee or its representative shall review the need for continued stay of each MA recipient admitted to the hospital.
(b) The hospital utilization review committee shall establish written criteria on which it bases a recipient’s need for continued stay. 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.
(c) The hospital utilization review committee shall assess the need for continued stay in the hospital by comparing each case to the written criteria established under subsection (b).
(d) The hospital utilization review committee shall assign a subsequent review date based on the recipient’s medical condition and the time continued hospitalization will no longer be necessary.
(e) The hospital utilization review committee 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, and the Department shall be notified before the expiration of the previously assigned length of stay.
(f) If the hospital utilization review committee fails to conduct the continued stay review or fails to notify the Department on or before the expiration of the previously assigned length of stay, the Department does not certify those hospital days between the expiration of the previously assigned length of stay and the date the request for continued stay is made and approved.
(g) If an individual applies for MA while in the hospital, the committee shall:
(1) Assign the continued stay review date within 1 working day after the hospital is notified that the individual has applied for MA.
(2) Contact the Department’s Concurrent Hospital Review (CHR) Section for approval of the assigned length of stay.
(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 continued stay.
(i) In the event of an adverse determination, the hospital utilization review committee shall follow the procedures under § 1163.480 (relating to adverse determinations).
Source The provisions of this § 1163.478 adopted June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185.
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); 55 Pa. Code § 1163.475 (relating to responsibilites of the hospital utilization review committee); and 55 Pa. Code § 163.477 (relating to admission review requirements).
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