10.07.01.14

.14 Utilization Review Agent.

A. Each hospital shall appoint a utilization review agent to carry out the requirements of the utilization review plan. When the agent is composed of hospital related personnel the hospital's plan shall expressly designate the positions and the organizational structure within the hospital that constitute the utilization review agent for that institution.

B. Each utilization review plan shall set forth the manner in which the agent:

(1) Utilizes the services of doctors of medicine or osteopathy and other practitioners capable of admitting patients, who are representative of practicing physicians in the area in which the hospital is located.

(2) Has available the services of sufficient numbers of physicians and dentists to assure the adequate review of medical specialty and subspecialty cases.

(3) Utilizes the services of registered nurses, medical records technicians, or similarly qualified persons supported and supervised by physicians in carrying out its review activities.

(4) Uses only a doctor of medicine, osteopathy, or dentistry to make a final determination that care rendered or to be rendered was, is, or may be medically inappropriate.

(5) Makes direct comparisons with professionally developed, objective criteria to determine the appropriateness of admission and continued stay. The criteria should:

(a) Be nationally recognized and accepted, unless a special exception is granted by the Secretary;

(b) Be capable of being utilized to define the type and extent of services which are to be considered as within the range of appropriate diagnosis and treatment for a given condition;

(c) Identify the level of care at which the services can appropriately and economically be rendered; and

(d) Recognize that for many conditions more than one mode or site of treatment or diagnosis may be medically acceptable.

(6) Collects information relevant to its function, maintains records, and reports to the Department as required. The hospital's utilization review plan shall outline the method by which patient confidentiality shall be maintained.

C. A member of the agent's staff, or any person that the agent may delegate or employ, may not review or make a determination of appropriateness for care that that person was directly responsible for providing, or which was provided by or to a member of that person's family.