N.Y. Comp. Codes R. & Regs. tit. 14 § 584.18

Current through Register Vol. 46, No. 45, November 2, 2024

Section 584.18 - Utilization review

(a) Each residential treatment facility shall have an organized utilization review program designed to monitor the appropriateness of continued stay and to identify the overutilization or underutilization of services.

(b) Each residential treatment facility shall prepare a written utilization review plan designed to ensure that there will be an ongoing utilization review program. This utilization review plan shall be subject to approval by the Office of Mental Health. The written utilization review plan shall address at a minimum:

(1) the establishment of a utilization review committee that shall be composed of at least three members of the clinical staff who meet the qualifications provided in section 584.10(d) of this Part, at least two of whom shall be physicians. The utilization review committee shall include at least one physician who is knowledgeable in the diagnosis and treatment of mental illness;

(2) the operating procedures of the utilization review committee, including convening meetings as often as necessary to execute its functions, but in no event less often than quarterly; maintaining written minutes of meetings; and submitting reports to the director. Utilization review committee members who are directly involved in the care of a resident whose care is being reviewed shall be excluded from the committee's deliberations;

(3) the integration of the utilization review program into the quality assurance program provided for in section 584.17 of this Part.

(c) The utilization review committee shall review each resident's continued stay in accordance with the following requirements:

(1) An initial continued stay review shall be completed by the utilization review committee or commissioner's designee no later than 30 days after admission.

(2) Subsequent continued stay reviews shall be completed by the utilization review committee or commissioner's designee 90 days after the initial continued stay review and every 90 days thereafter.

(3) Review of each alternate care determination by the utilization review committee or a subcommittee of the utilization review committee which includes at least one physician.

(4) Notification of the physician on the resident's interdisciplinary treatment team of an alternative determination. Additional information provided by such physician shall be considered by the utilization review committee that includes at least two physicians.

(5) Notification of the director of final adverse decisions.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 584.18

Amended New York State Register July 3, 2024/Volume XLVI, Issue 27, eff. 7/3/2024