Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter B - HOSPITALS AND HOSPITAL UNITS UNDER COST REIMBURSEMENT PRINCIPLES › UTILIZATION CONTROL › Section 1163.477 - Admission review requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The hospital utilization review committee
					 or its representative shall review the need for admission of each MA recipient
					 admitted to the hospital within 24 hours after admission. The committee shall
					 make a final determination of the need for admission within 2 working days
					 after admission, unless the case or category of admission is designated for
					 preadmission review.
(b) The
					 hospital 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.
(c) The hospital utilization review committee
					 shall assess the need for hospital inpatient services by comparing each
					 admission to the hospital's written criteria established in accordance with
					 subsection (b).
(d) Except as noted
					 in subsection (e), an initial length of stay for general hospitals must be no
					 greater than the 50th percentile of the latest Hospital Utilization Project
					 (HUP) length of stay guidelines per diagnosis category, per age group. Ten days
					 will be assigned as the initial length of stay for rehabilitation hospitals
					 when the HUP 50th percentile for the admitting diagnosis is 10 days or less
					 with the actual HUP 50th percentile used to assign the initial length of stay
					 for other admissions. The HUP length of stay guidelines appear in the HUP
					 Length of Stay Manual designated by the Department, and are statistical tables
					 reflecting the length of stay of inpatient hospital stays in the Mid-Atlantic
					 Region of the United States.
(e) If
					 a recipient's diagnosis is unconfirmed upon admission, the hospital utilization
					 review committee, or its representative, shall assign an initial length of stay
					 of no more than 2 days. If the committee is unable to confirm the recipient's
					 diagnosis within 2 days, the committee shall notify the Department's Concurrent
					 Hospital Review unit and initiate continued stay review in accordance with
					 §
											1163.478 (relating to continued
					 stay review requirements).
(f) 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
					 admission.
(g) In the event of an
					 adverse determination, the hospital utilization review committee shall follow
					 the procedures in §
											1163.480 (relating to adverse
					 determinations).
(h) The hospital
					 utilization review committee shall conduct a review of cases identified by the
					 Office of MA Programs, as being a questionable utilization of hospital services
					 and facilities.
The provisions of this §
													1163.477 amended under sections
						  201 and 443.1(1) of the act of June 13, 1967 (P. L. 31, No. 21) (62 P. S.
						  §§
														201 and
						  443.1(1)).
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); and 55 Pa. Code §
													1163.475 (relating to
						  responsibilities of the hospital utilization review
						  committee).