C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-46, subsec. 144-101-II-46.11

Current through 2024-51, December 18, 2024

Subsection 144-101-II-46.11 - HOSPITAL UTILIZATION REVIEW PLAN REQUIREMENTS

Each Psychiatric Hospital must have in effect a written Utilization Review Plan that provides for review of each member's need for inpatient, partial hospitalization or outpatient services furnished by the hospital and must meet the following requirements:

46.11-1Utilization Review Committee

A.Utilization Review Plan

The Plan must:

1. Provide for a committee to perform the Utilization Review activities described in this manual;

2. Describe the organization, composition and functions of the committee; and

3. Specify the frequency of meetings of the committee.

B.Organization and Composition of the Utilization Review Committee

The Utilization Review Committee must be composed of two or more physicians, at least one of whom is knowledgeable in the diagnosis and treatment of mental diseases.

C.Disqualification From Committee Membership

The Utilization Review Committee must be constituted as a committee of the hospital staff and may not include any individual who:

1. Is directly responsible for the care of members whose care is being reviewed; or

2. Has a financial interest in any inpatient psychiatric hospital.

46.11-2Information Requirements

A.Member Information

The Utilization Review Plan must provide that each member's record include information needed to perform Utilization Review under this manual. This information must include, at least, the following:

1. The member's name;

2. The name of the member's physician;

3. Date of initiation of service and, if application is made after initiation of service, dates of application for and authorization of MaineCare benefits;

4. The plan of care described in section 46.10, above;

5. Initial and subsequent continued service review dates described under Section 46.09;

6. Reasons and plan for continued service, if the attending physician believes continued service is necessary;

7. Other supporting material that the committee believes appropriate for inclusion in the record.

B.Records and Reports

The Utilization Review plan must describe:

1. The types of records that are kept by the committee and

2. The type and frequency of committee reports and arrangements for their distribution to appropriate members.

C.Confidentiality

The Utilization Review plan must provide that the identities of members in all Utilization Review records and reports are kept confidential.

46.11-3Review of Need for Continued Stay for Inpatient Services

A.Continued Stay Review Required

The Utilization Review plan must provide for a review of each member's continued stay in the inpatient psychiatric hospital to decide whether it is needed, in accordance with the requirements of 46.11-3 (B) through (H).

B.Evaluation Criteria for Continued Stay

The Utilization Review plan must provide that:

1. The committee develops written medical care criteria to assess the need for continued stay.

2. The committee develops more extensive written criteria for cases that its experience shows are:

a. Associated with high costs;

b. Associated with the frequent furnishing of excessive services; or

c. Attended by physicians whose patterns of care are frequently found to be questionable.

C.Initial Continued Stay Review Date

The Utilization Review Plan must provide that:

1. When a member is admitted to the inpatient psychiatric hospital under admission review requirements of this manual the committee assigns a specified date by which the need for his/her continued stay will be reviewed;

2. If an individual applies for MaineCare while in the hospital, the committee assigns the initial continued stay review date within one (1) working day after the hospital is notified of the application for MaineCare;

3. The committee bases its assignment of the initial continued stay review date on:

a. The methods and criteria required to be described under 46.11-3 (E) below,

b. The member's condition, and

c. The member's projected discharge date.

4. The committee uses any available appropriate regional medical care appraisal norms, such as those developed by abstracting services or third party payors, to assign the initial continued stay review date;

These norms are based on current and statistically valid data on duration of stay for inpatient psychiatric hospitals for members whose characteristics, such as age and diagnosis, are similar to those of the member whose need for continued stay is being reviewed;

If the committee uses norms to assign the initial continued stay review date, the number of days between the member's admission and the initial continued stay review date is no greater than the number of days reflected in the 50th percentile of the norms. However, the committee may assign a later review date if it documents that the later date is more appropriate;

5. The initial continued stay review date is not in any case later than thirty (30) days after admission of the member or thirty (30) days after notice to the inpatient psychiatric hospital of his application for MaineCare; and

6. The committee insures that the initial continued stay review date is recorded.

D.Subsequent Continued Stay Review Dates

The Utilization Review plan must provide that:

1. The committee assigns subsequent continued stay review dates in accordance with 46.11-3(C), above, and 46.11-3(E), below

2. The committee assigns a subsequent continued stay review date within sixty (60) days each time it decides under 46.11-3(F) below that the continued stay is needed, until one hundred and twenty (120) days of service has been provided, and within thirty (30) days each time it decides under 46.11-3(F) below that a continued stay is needed after one hundred and twenty (120) days of service has been provided, and

3. The committee insures that each continued stay review date it assigns is recorded.

E.Description of Methods and Criteria; Continued Stay Review Dates; Length of Stay Modification

The Utilization Review plan must describe:

1. The methods and criteria, including norms if used, that the committee uses to assign initial and subsequent review dates under 46.11-3(C) and (D), above,

2. The methods that the committee uses to modify an approved length of stay when the member's condition or treatment schedule changes.

F.Continued Stay Review Process

The Utilization Review plan must provide that:

1. Review of continued stay cases is conducted by one of the following:

a. The Utilization Review Committee;

b. A subgroup of the Utilization Review Committee or

c. A designee of the Utilization Review Committee;

2. The committee, subgroup, or designee reviews a member's need for continued stay on or before the expiration of each assigned continued stay review date;

3. For each continued stay of a member in the inpatient psychiatric hospital, the committee, subgroup or designee reviews and

4. evaluates the documentation described under 46.11-2 against the criteria developed under 46.11-3(B) and applies close professional scrutiny to cases described under 46.11-3(B)(2).

5. If the committee, subgroup or designee finds that a member's continued stay in the inpatient psychiatric hospital is needed, the committee assigns a new continued stay review date in accordance with 46.11-3(D).

6. If the committee, subgroup, or designee finds that a continued stay case does not meet the criteria, the committee or a subgroup that includes at least one physician reviews the case to decide the need for continued stay;

7. If the committee or subgroups making the review under (5) of this Section finds that a continued stay is not needed, it notifies the member's attending or staff physician and gives him/her an opportunity to present his/her views before it makes a final decision on the need for the continued stay;

8. If the attending or staff physician does not present additional information to establish the need for the continued stay, the decision of the committee or subgroup is final; and

9. If the attending or staff physician presents additional information or clarification, at least two (2) physician members of the committee, one of whom is knowledgeable in the treatment of mental diseases, review the need for the continued stay. If they find that the member no longer needs inpatient psychiatric hospital services their decision is final.

G.Notification of adverse decision

The Utilization Review plan must provide that written notice of any adverse final decision, based on (1) through (8), above, disaffirming the need for continued stay above is sent to:

1. The hospital administrator;

2. The attending or staff physician;

3. The hospital reimbursement officer;

4. The member;

5. The next of kin, legal guardian, or sponsor;

6. The third party payor or MaineCare Office of Integrated Access and Support (OIAS); and

7. The Department and its Authorized Agent.

H.Time limits for final decision and notification of adverse decision

The Utilization Review plan must provide that the committee makes a final decision concerning a member's need for continued stay and gives notice of an adverse decision within two (2) working days after the assigned continued stay review date. If the committee makes a final decision denying a member's need for continued stay before the assigned review date, notice under (G) above, is given within two (2) working days after the date of the final decision.

46.11-4Medical Care Evaluation for Psychiatric Hospital Services

A.Purpose and General Description

The purpose of medical care evaluations is to promote the most effective and efficient use of available health hospitals and services consistent with members' needs and professionally recognized standards of health care.

Medical care evaluations:

1. Emphasize identification and analysis of patterns of member care, and

2. Suggest appropriate changes needed to maintain consistently effective and efficient use of services.

B.Utilization Review Plan Requirements for Medical Care Evaluation

The Utilization Review plan must describe the methods that the committee uses to select and conduct medical care evaluations.

The Utilization Review plan must provide that the Utilization Review committee:

1. Determines the methods to be used in selecting and conducting medical care evaluations;

2. Documents the results of each evaluation and how the results have been used to make changes to improve the quality of care and promote more effective and efficient use of hospitals and services;

3. Analyzes the findings for each evaluation; and

4. Takes action as needed to correct or investigate further any deficiencies or problems in the review process and to recommend more effective and efficient hospital care procedures.

C.Content of Medical Care Evaluations

Each medical care evaluation must include the following:

1. Identification and analysis of medical or administrative factors related to member care;

2. Analysis of at least the following:

a. Admissions;

b. Duration of care;

c. Ancillary services furnished, including drugs and biologicals; and

d. Professional services performed.

3. If indicated, recommendations for change beneficial to members, staff, the hospital, and the community.

D.Data Sources For Evaluations

Data that the committee uses to perform evaluations must be obtained from one or more of the following sources:

1. Medical records or other appropriate hospital data;

2. External organizations that compile statistics, design profiles, and produce other comparative data; or

3. Cooperative endeavors with:

a. PSROs/PROs,

b. Fiscal agents,

c. Other service providers, and

d. Other appropriate agencies.

E.Numbers Of Evaluations Required To Be Performed

The psychiatric hospital must have at least one (1) evaluation in progress at any time and complete one (1) evaluation each calendar year.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-46, subsec. 144-101-II-46.11