Information Upon Which Utilization Review is Conducted
1. When conducting routine prospective and concurrent utilization review, the private review agent shall collect only the information necessary to certify the admission, procedure or treatment and length of stay.2. A private review agent should not routinely expect hospitals and physicians to supply numerically codified diagnoses or procedures. The private review agent may ask for such coding, since if it is known, its inclusion in the data collected increases the effectiveness of the communication.3. The private review agent shall not routinely request copies of medical records on all patients reviewed. During prospective and concurrent review, copies of medical records should only be required when a difficulty develops in certifying the medical necessity or appropriateness of the admission or extension of stay. In those cases, only the necessary or pertinent sections of the record should be required.4. Private review agents may request copies of medical records retrospectively for a number of purposes, including auditing the services provided, quality assurance, evaluation of compliance with the terms of the health benefit plan or UR provisions. With the exception of the reviewing of records associated with an appeal or with an investigation of data discrepancies and unless otherwise provided for by contract or law, health care providers should be reimbursed the reasonable direct costs of duplicating requested records for retrospective review.15 Miss. Code. R. § 16-1-82.7.2