Section 455.20 - Utilization review

455.20 Utilization review. This functional reporting center must contain all the expenses associated with providing utilization review. Reference: section 416.9 of this Subchapter. Additional activities include but are not limited to the following: conducting ongoing evaluation of the quality of care provided. This includes periodic review of utilization of bed facilities and of the diagnostic, nursing and therapeutic resources of the residential health care facility with respect to availability of these resources to all patients according to their medical needs, and recognition of the medical practitioner's responsibility for the costs of health care. This review should cover necessity of admission (including concurrent review of admission), length of stay, level of care, quality of care, utilization of ancillary services, professional services furnished, and availability and alternative use of facilities and services. The review committee should include two or more physicians with participation of other professional personnel, or a group outside the facility which is similarly composed and which is established by the local medical society and some or all of the residential health care facilities in the locality, or a group established and organized in a manner approved by the Department of Health that is capable of performing such function.

(a) Standard unit of measure: number of cases reviewed. The total number of patient cases reviewed by the Utilization Review Committee. If a case is reviewed more than once, it should be counted as a case reviewed, each time reviewed.

(b) Data source. The number shall be determined from an actual count maintained in the Utilization Review Committee.
 

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