Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › UTILIZATION CONTROL › Section 1151.75 - Admission review requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The utilization review committee or its
				  representative shall review the need for admission of each recipient admitted
				  to the inpatient psychiatric facility within 24 hours of the
				  admission.
(b) The utilization
				  review committee or its representative shall make a final determination of each
				  recipient's need for admission within 2 working days after the
				  admission.
(c) The utilization
				  review committee shall establish written criteria on which it bases a
				  recipient's need for admission. The criteria 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.
(d) The
				  utilization review committee or its representative shall assess the need for
				  inpatient psychiatric services by comparing each admission to the written
				  criteria established in accordance with subsection (c).
(e) Except as noted in subsection (f), the
				  utilization review committee or its representative shall use the Hospital
				  Utilization Project (HUP) 50th percentile length of stay guidelines in
				  assigning an initial length of stay.
(f) If a recipient's diagnosis is unconfirmed
				  upon admission, the utilization review committee or its representative shall
				  assign an initial length of stay of no more than 2 days. If the utilization
				  review committee is unable to confirm the recipient's diagnosis within 2
				  working days, the committee shall notify the Department's Concurrent Hospital
				  Review Section and initiate continued stay review in accordance with §
										1151.76 (relating to continued
				  stay review requirements).
(g) The
				  utilization review committee shall allow the attending physician the
				  opportunity to present his views before making a final decision on the need for
				  admission.
(h) In the event of an
				  adverse determination, the utilization review committee shall follow the
				  procedures set forth in §
										1151.78 (relating to adverse
				  determinations).
(i) The
				  utilization review committee shall conduct a review of cases identified by the
				  Department as being a questionable utilization of inpatient psychiatric
				  services and facilities.
The provisions of this §
												1151.75 amended under sections 201
						and 443.1(1) of the Public Welfare Code (62 P. S.
						§§
													201 and
						443.1(1)).
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); and 55 Pa. Code §
												1151.74 (relating to
						responsibilities of the inpatient psychiatric facility utilization review
						committee).