10.07.01.15

.15 Performance Standards for Utilization Review.

The hospital's program shall apply to all patients with the exceptions of those noted in Regulation .17, below. Except when noted for certain types of review, the program may delineate certain types and kinds of cases to be reviewed, so as to most efficiently carry out the purposes of these regulations. As a minimum, the hospital utilization review program shall satisfy the following performance standards:

A. Pre-admission Review.

(1) A review of those elective admissions identified under the plan shall be performed by the agent in advance of the proposed admission.

(2) The purpose of this review shall be to determine the reasonableness and medical necessity of the admission, and the appropriateness of the level of proposed care.

(3) In conducting the review, the agent may supplement the information provided by the hospital through discussion with the patient's physician.

(4) The agent, using specific medical criteria, shall render a decision as to whether the admission is medically appropriate within 3 working days of the time it receives the case, except in those circumstances when responding within this period would not permit sufficient consultation or discussion to render a responsible opinion.

B. Post-admission Review.

(1) For those categories of emergency admissions identified for review in the hospital's plan, the agent shall carry out a review to ascertain the:

(a) Reasonableness and medical necessity of the admission;

(b) Appropriateness of the level of care provided; and

(c) Justification for the non-elective nature of the admission.

(2) The agent shall be notified by the hospital within 24 working hours of the admission and the agent shall carry out the review within 3 working days of notification, except in cases when appropriate consultation cannot be carried out in this period of time.

C. Concurrent or Retrospective Review.

(1) For patients included in the plan the agent shall determine whether each day of the patient's hospitalization was medically necessary and appropriate based upon nationally recognized criteria. The agent shall also designate those days of hospitalization caused by administrative requirements including days on which patients await appropriate placement or equipment needed after discharge.

(2) The review may be concurrent with the patient's stay or take place after the patient is discharged.

(3) Days designated as administrative shall be found appropriate only if approved under discharge planning review, as discussed in §F.

D. Pre-authorization Review.

(1) The agent shall review prospectively all elective admissions in which one or more of the plan designated procedures is the principal procedure being performed for that admission.

(2) The procedures for which pre-authorization is required are set forth in Regulation .21.

(3) The agent may approve inpatient treatment for the listed procedures only if there is documentation that equivalent outpatient treatment would not be medically appropriate for the patient.

(4) All non-elective admissions that have not been pre-authorized and that subsequently involve performance of one or more of the plan designated procedures shall be reviewed concurrently or retrospectively by the agent.

E. Objective Second Opinion.

(1) Before an elective admission for a surgical procedure designated below, the patient shall obtain an objective second opinion.

(2) The procedures for which a second opinion is required are set forth in Regulation .22.

(3) The second opinion may be rendered by any physician of the patient's choosing except a physician having any financial relationship with the patient's original physician.

(4) Should a voluntary admission not take place within 6 months of the rendering of the second opinion, then another opinion shall be sought before admission.

(5) The agent may waive the requirement for obtaining a second opinion because:

(a) Obtaining the second opinion would impose a hardship on the patient; or

(b) The patient's medical insurance does not cover second opinions, and was:

(i) Issued and delivered in another state, and

(ii) Not intended to cover persons living or working in Maryland.

F. Discharge Planning.

(1) The utilization review plan shall set forth the hospital's discharge planning procedures.

(2) The agent shall review the effectiveness of the hospital's discharge planning.

(3) The agent shall review those days of care which have been designated to be administrative as a result of the agent's concurrent or retrospective review.

(4) Administrative days may be approved as necessary and appropriate only if evidence can be found that the hospital has developed and implemented a discharge plan at the earliest possible time and there is evidence that appropriate placement efforts have been made.

G. Continued Stay Review. For patients in beds licensed for long term care, the agent shall periodically review and certify as appropriate the level of care and placement, and the medical necessity of treatment prescribed.

H. Re-admission Review. The agent shall review the appropriateness of the previous discharge and the indications for admission for hospitalizations occurring shortly after a previous discharge.