55 Pa. Code § 1163.481 - Utilization review sanctions
(a) The
Office of MA Programs regularly monitors each hospitals utilization review
program to determine whether or not it is operating under the Concurrent
Hospital Review process and this part. Monitoring is carried out through review
of admissions, continued stays, patient records and claims paid by the
Department.
(b) If the Department
identifies delays in assigning the initial or continued length of stay, the
Department will deny payment for all or part of the hospital stay.
(c) If the Department determines that
services or items provided by the hospital were not medically justified, or
were unnecessary, inappropriate or noncompensable, the Department will deny
payment for the service or item and for services related to the provision of
that service or item. Payment will also be denied to the practitioner who
ordered the service.
Notes
The provisions of this § 1163.481 amended under sections 201 and 443.1(1) of the Public Welfare Code (62 P. S. §§ 201 and 443.1(1)).
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