No. 39452 (Amendment): Section R414-1-12. Utilization Review

(Amendment)

DAR File No.: 39452
Filed: 06/17/2015 01:30:23 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to remove the Superior System Waiver as the source for hospital utilization review and replace it with the Hospital Services Utah Medicaid Provider Manual, based on direction from the Centers for Medicare and Medicaid Services.

Summary of the rule or change:

This amendment removes the Superior System Waiver as the source for hospital utilization review and replaces it with the Hospital Services Utah Medicaid Provider Manual.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this amendment only changes the source for hospital utilization review but not the procedures themselves.

local governments:

There is no impact to local governments because this amendment only changes the source for hospital utilization review but not the procedures themselves.

small businesses:

There is no impact to small businesses because this amendment only changes the source for hospital utilization review but not the procedures themselves.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid providers and to Medicaid recipients because this amendment only changes the source for hospital utilization review but not the procedures themselves.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because this amendment only changes the source for hospital utilization review but not the procedures themselves.

Comments by the department head on the fiscal impact the rule may have on businesses:

This amendment has no fiscal impact on business because it does not change hospital utilization review procedures.

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

08/14/2015

This rule may become effective on:

08/21/2015

Authorized by:

David Patton, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-1. Utah Medicaid Program.

R414-1-12. Utilization Review.

(1) The Department conducts hospital utilization review as outlined in the [Superior System Waiver]Hospital Services Utah Medicaid Provider Manual in effect at the time service [was]is rendered.

(2) The Department shall determine medical necessity and appropriateness of inpatient admissions during utilization review by use of InterQual Criteria, published by McKesson Corporation.

(3) The standards in the InterQual Criteria shall not apply to services in which a determination has been made to utilize criteria customized by the Department or that are:

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

(b) provided in an intensive physical rehabilitation center as described in Rule R414-2B; or

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

In these exceptions, or where InterQual is silent, the Department shall approve or deny services based upon appropriate administrative rules or its own criteria as incorporated in the Medicaid provider manuals.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [June 1, ]2015

Notice of Continuation: March 2, 2012

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-34-2

 

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