10.07.01.13

.13 Utilization Review Plan.

A. Before October 1, 1985, each hospital shall submit a proposed utilization review plan to the Secretary.

B. Effective October 1, 1985, each hospital shall have in effect a utilization review plan approved by the Secretary pursuant to this chapter.

C. The purpose of the hospital's utilization review program, as defined by the plan, shall be to determine for patients included in the hospital's review responsibilities the:

(1) Reasonableness and medical necessity of care given or proposed to be given at the hospital;

(2) Quality of care given at the hospital; and

(3) Appropriateness of the level of care proposed or given, including whether the care could be or could have been provided appropriately and more economically on an outpatient basis or in a facility that provides a lower level of care.

D. A utilization review plan shall:

(1) Identify the designated utilization review agent;

(2) Describe the criteria to be used in evaluating proposed or delivered hospital care;

(3) Delineate the types and kinds of cases that the agent will review and the circumstances under which either some or all patients in the hospital, or within specific diagnostic groups, will be selected;

(4) Make provisions for the collecting, storing, and reporting of data;

(5) Define measures by which the agent can evaluate the effectiveness of its program;

(6) Make provisions for screening medical records pertaining to patients for which the agent has review responsibility in order to identify and verify problems in the quality of care;

(7) Establish a mechanism through which patients, physicians, or third-party payers may seek reconsideration of decisions made by the utilization review agent;

(8) Detail how each of the following elements is to be performed by the agent:

(a) Pre-admission review of elective admissions;

(b) Post-admission review of nonelective admissions;

(c) Concurrent or retrospective review of admissions;

(d) Pre-authorization of certain selected procedures proposed to be performed on an inpatient basis;

(e) Institution of an objective second surgical opinion protocol to evaluate the desirability of performing selected surgical procedures on an elective basis;

(f) Discharge planning review;

(g) Continued stay review; and

(h) Re-admission review;

(9) Meet all other requirements for utilization review promulgated by the Secretary.