Utah Admin. Code R414-1-12 - Utilization Review

(1) The Department shall conduct hospital utilization reviews as outlined in the Hospital Services Utah Medicaid Provider Manual. The Department shall use the Hospital Services Utah Medicaid Provider Manual in effect at the time the service is rendered.

(2) The Department shall determine medical necessity and appropriateness of inpatient admissions through utilization reviews. Utilization reviews shall use an evidence-based criteria tool determined by the Department through the state's procurement process.

(3) The Department shall seek a contract implemented through a competitive solicitation process in accordance with Title 63G, Chapter 6a, Utah Procurement Code.

(4) The standards in the evidence-based criteria may not apply to services in which a determination has been made to utilize the following criteria:

(a) criteria customized by the Department;

(b) criteria excluded as a Medicaid benefit by rule or contract; or

(c) criteria for organ transplant services as described in Rule R414-10A.

(5) The Department shall approve or deny services based upon administrative rules or its own criteria set forth in the Medicaid provider manuals when the exceptions in Subsection R414-1-12(4) exist.

Notes

Utah Admin. Code R414-1-12

Amended by Utah State Bulletin Number 2015-20, effective 9/22/2015 Amended by Utah State Bulletin Number 2020-19, effective 10/1/2020