N.Y. Comp. Codes R. & Regs. tit. 14 § 676.7

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

Section 676.7 - Utilization review

(a) Each diagnostic and research clinic shall have a utilization review committee and a written utilization review plan for evaluation of the need for services provided to persons with developmental disabilities. The same utilization review plan and the utilization review committee for internal utilization reviews shall address and review the diagnostic and research clinic's nonresidential component and its residential unit (i.e., the ICF/DD), so as to review the person's eligibility for services (resident/nonresident) at this level of care. The utilization review committee and the utilization review plan shall comply with the following requirements:

(1) Committee composition.

(i) The utilization review committee shall be composed of professionals including at least:

(a) one physician;

(b) one person who is a qualified intellectual disability professional; or

(c) other professional staff representing the disciplines at the diagnostic and research clinic.

(ii) Additionally, the committee may and is encouraged to include:

(a) a representative of the local director of community services; and

(b) representative(s) from other programs affiliated with the diagnostic and research clinic and/or other programs giving services to persons being assessed by the clinic.

(iii) No member of the utilization review committee shall participate in the committee's deliberations regarding any person he or she is directly treating.

(2) Utilization review plan.

(i) Each diagnostic and research clinic shall have a separate written utilization review plan approved by the director and/or governing body, and by the bureau of utilization review of OPWDD.

(ii) The bureau of utilization review shall be responsible for reviewing each diagnostic and research clinic's plan and certifying to the appropriate State and Federal agencies that the plan meets all regulatory requirements.

(iii) The utilization review committee shall develop a plan for review to indicate at least:

(a) the criteria for providing each service;

(b) the methods for conducting review of admission appropriateness, authorization of specialized medical and clinical laboratory services, residential services, team planning conferences, and other optional services; or

(c) the requirements for conducting admission reviews prior to giving any services, and the requirements for conducting continued treatment reviews after services authorized at the intake screening have been delivered, and subsequent treatment reviews after corollary or supplemental services are given at follow-up visits to the clinic.

(iv) The utilization review plan shall require the utilization review committee to use the forms and criteria prescribed by OPWDD in accordance with instructions provided by the commissioner.

(v) The utilization review plan shall include requirements for a monthly report submitted to the commissioner of OPWDD. This report shall:

(a) summarize the activities of the utilization review committee; and

(b) include a copy of each notice of alternative care.

(vi) The utilization review committee shall keep minutes of its meetings sufficiently detailed to document its decisions and the basis for them so as to enable auditing by the local commissioner of social services or his or her designee, by any other authorized person or agency, or by OPWDD.

(b) In addition to the internal utilization review required by this section, OPWDD shall ensure the provision of at least one annual independent validation review of the population served by the clinic and the services provided at the clinic. This review shall determine the appropriateness of the level of service being provided.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 676.7

Amended New York State Register September 21, 2016/Volume XXXVIII, Issue 38, eff. 9/21/2016