R414-1-12. Utilization Review

  (1) The Department conducts hospital utilization review as outlined in the Hospital Services Utah Medicaid Provider Manual in effect at the time service 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.