10.07.01.19

.19 Reports to the Secretary.

A. Each hospital shall report annually to the Secretary the following summary statistics on the activity of its utilization review program:

(1) The number of discharges and total patient days reviewed under the program;

(2) For each of the procedures requiring pre-authorization for inpatient treatment, the number of patients:

(a) Reviewed; and

(b) Approved for inpatient treatment;

(3) For each of the procedures requiring an objective second opinion, the number of patients:

(a) Undergoing the procedure at the hospital;

(b) Admitted non-electively for the procedure;

(c) Admitted electively after the patient had obtained a second opinion; and

(d) Admitted electively but for whom the requirement of a second opinion was waived, including a tabulation of the reasons for waivers;

(4) For admissions reviewed concurrently or retrospectively, the number of all reviewed admissions disapproved, and reasons for disapproval;

(5) The number of all reviewed days of hospitalization disapproved, by reason for disapproval;

(6) A summary of the findings of re-admission review, including the frequency and proportion of these cases, the diagnoses or treatments involved, and the reasons found;

(7) A listing and description of quality care problems found by the agent in the course of reviewing patient records in furtherance of its duties under the utilization review plan.

B. The Secretary shall be allowed access to hospital patient records and to the records of the hospital's utilization review agent pertaining to review activities under the plan for the purpose of enforcing these regulations.