55 Pa. Code § 1163.480. Adverse determinations.

§ 1163.480. Adverse determinations.

(a)  If the hospital utilization review committee denies admission or continued stay, the committee shall forward a letter regarding the adverse determination to:
   (1)  The recipient.
   (2)  The recipient’s next of kin or sponsor, if applicable.
   (3)  The attending physician.
   (4)  The hospital administrator.
   (5)  The Office of MA Programs.
(b)  The adverse determination letter shall include:
   (1)  The patient’s name.
   (2)  The patient’s age.
   (3)  The patient’s full MA number.
   (4)  The hospital’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 hospital 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, based on lack of medical necessity, the hospital shall attach a copy of the adverse determination letter to the invoice submitted for payment.
(e)  Each month the hospital utilization review committee shall complete and submit to the Office of Medical Assistance Programs a summary report of adverse determinations in accordance with the instructions in the Provider Handbook or in the Manual for Concurrent Review of Inpatient Hospital Services.
(f)  The hospital utilization review committee shall mail the monthly summary report specified in subsection (e) within 5 days after the end of the month.

Authority

   The provisions of this §  1163.480 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 §  1169.480 adopted June 22, 1984, effective July 1, 1984, 14 Pa.B. 2185; 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 (181893) to (181894).

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 §  1163.477 (relating to admission review requirements); and 55 Pa. Code §  1163.478 (relating to continued stay review requirements).

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