10.07.01.18

.18 Record Maintenance by Utilization Review Agents.

A. The plan shall describe how, in addition to maintaining documents which describe its utilization review procedures, the agent shall maintain the following records for each individual patient for whom any aspect of the utilization review procedure has been applied:

(1) The patient's name, hospital history number, source of payment, and other demographic information capable of identifying the patient.

(2) The principal diagnosis or diagnoses (with corresponding codes listed in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) as defined in COMAR 10.09.06.01P), and the particular category of patient chosen for review in accordance with the hospital's utilization review plan.

(3) The date or dates on which review activities were requested and the date or dates on which opinions were rendered.

(4) The type of review carried out, the nature of the criteria applied, and the results of the review. In the case of disallowed services, the reasons for disallowance shall be stated, as well as the name of the physician member of the agent's staff making the final disallowance determination.

(5) In the case of objective second opinions, documentation shall include the name of the physician rendering the second opinion, the physician's specialty, and the nature of the opinion.

B. Each agent shall maintain a listing of all reviewed cases suitable for the selection of a sample of all cases reviewed within each 2-year certification period.