R414-2A-10. Utilization Control and Review Program for Hospital Services

  The Hospital Utilization Review Program is administered and operated in accordance with Title 63A, Chapter 13.

  (1) The purpose of the hospital utilization review program is to ensure:

  (a) efficient and effective delivery of services;

  (b) services are appropriate and medically necessary;

  (c) service quality is maintained; and

  (d) the State satisfies federal requirements for a statewide surveillance and utilization control program.

  (2) The Hospital Utilization Review Program shall conduct assessments and audits to ensure the appropriateness and medical necessity of the following:

  (a) Admissions to a hospital or a designated distinct part unit within a hospital;

  (b) Transfers from one acute care hospital to another acute care hospital, or to an inpatient rehabilitation hospital or psychiatric unit in another acute care hospital (inter-facility transfer);

  (c) Transfers from an acute care setting to an inpatient rehabilitation unit of a hospital or psychiatric unit within the same facility (intra-facility transfer);

  (d) Continued stays;

  (e) Services, surgical services and diagnostic procedures;

  (f) Principal diagnosis, principal surgical procedure or both, reflected on paid claims to ensure consistency with the attending physician's determination and documentation as found in the member's medical record;

  (g) Determine whether co-morbidity, as found on the claim, is correct and consistent with the attending physician's determination and compatible with documentation found in the member's medical record; and

  (h) Quality of care.

  (3) The Hospital Utilization Review Program shall conduct assessments and audits to determine:

  (a) Appropriate utilization;

  (b) Compliance with state and federal Medicaid regulations;

  (c) Whether documentation meets state and federal requirements for sufficiency, and whether it accurately describes the status of services provided to the member; and

  (d) Whether procedures that require prior authorization have been approved before the provision of services, except in cases that meet the criteria listed in the Utah Medicaid Section 1: General Information Provider Manual (Retroactive Authorization).

  (4) The Hospital Utilization Review Program shall make determinations of medical necessity, appropriateness of care, and suitability of discharge planning in accordance with the following criteria and protocols:

  (a) InterQual Criteria;

  (b) Administrative rules or criteria developed by Medicaid for programs and services not otherwise addressed; and

  (c) DRGs.

  (5) Hospital Utilization Readmission Policy and Reviews.

  (a) Whenever information available to the reviewer indicates the possibility of readmission to acute care within 30 days of the previous discharge, the staff administering and operating the Hospital Utilization Review Program may review any claim for:

  (i) Readmission for the same or a similar diagnosis to the same hospital, or to a different hospital;

  (ii) Appropriateness of inter-facility transfers; and

  (iii) Appropriateness of intra-facility transfers.

  (b) The Hospital Utilization Review Program shall review all suspected readmissions within 30 days of a previous discharge to ensure that Medicaid criteria have been met for severity of illness, intensity of service, and appropriate discharge planning and financial impact to the Department as noted in Subsection R414-2A-10(3).

  (c) If a member is readmitted for the same or similar diagnosis within 30 days of discharge and, if after review as described in Subsection R414-2A-10(5)(b), program review staff determines that readmission does not meet the criteria in Subsection R414-2A-10(3)(b), then the payment shall be combined into a single DRG payment, unless it is cost effective to pay for two separate admissions. The first DRG (initial admission) shall be the DRG that is paid. This policy does not apply to cases related to pregnancy, neonatal jaundice, or chemotherapy.

  (6) Definition, Policy Application.

  (a) When applying policy, a similar diagnosis is defined as:

  (i) Any diagnoses code with similar descriptors;

  (ii) Any exchange or combination of principal and secondary diagnosis; and

  (iii) Any other sets of principal diagnoses established to be similar by Utah Medicaid policy in written criteria and published to the hospitals prior to service dates.

  (b) The evaluation criteria for utilization control are severity of illness, intensity of service, and cost effectiveness as noted in Subsection R414-2A-10(5)(b).

  (7) Appropriate remedial action will be initiated for inappropriate readmissions when identified though the hospital utilization post-payment review process.

  (8) Applicability to Outpatient Hospital Services.

  (a) When a Medicaid member is readmitted to the hospital, or readmitted as an outpatient within 30 days of a previous discharge for the same or similar diagnosis, Medicaid will evaluate both claims to determine if they should be combined into a single payment or paid separately.

  (9) Recovery of Funds.

  (a) The Department shall recover payment when post-payment review finds that services are not medically necessary, not appropriate, or that quality of service is not suitable.

  (b) The Department shall recover payment when it determines there is a violation of the 30-day re-admission policy.

  (10) Hospital Utilization Review.

  (a) Each month, the Hospital Utilization Review Program shall review at least 5 percent of a selected universe of claims adjudicated in the previous month. At least 2.5 percent of the claims shall be a random sample. Up to 2.5 percent may be a focused review on a specific service. A staff decision to focus on a specific service shall be made no later than the beginning of the sample cycle.

  (b) The Department shall select the universe from paid inpatient hospital claims within the Data Warehouse. The universe from which the random sample is selected is defined as all inpatient hospital claims adjudicated before the beginning of the review cycle, except for:

  (i) Claims showing, as a principal diagnosis, any International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) delivery code in the ICD-10-CM Manual Chapter 15 -- Pregnancy, Childbirth, and the Puerperium, in the range of O00 through O9A.53, and other ICD-10-CM codes or DRG or DRGs as specified by policy or administrative decision.

  (ii) Claims that show $0 payment by Medicaid;

  (iii) Medicare crossover claims;

  (iv) Claims with other codes or diagnoses determined by the review program staff to be inappropriate for review.

  (c) The sample cycle shall begin on the first working day of each month.

  (11) Utah State Hospital Utilization Review.

  (a) The purpose of this utilization review is to ensure that Medicaid funds, as defined under 42 CFR 456, Subpart D, are expended appropriately and to ensure that services provided to Medicaid members at the Utah State Hospital (USH) are necessary and of high quality. Review program staff shall conduct oversight activities at USH.

  (b) Oversight activities include quarterly clinical utilization reviews in which program staff review a sample of members who are under 21 years of age and are 65 years of age or older, and who were reviewed by USH utilization review staff during a previous quarter. These reviews are performed to:

  (i) Evaluate the USH utilization process; and

  (ii) Address the clinical topic selected for that quarter's review.

  (c) Reviews of USH Quality Improvement and Quality Assurance programs are conducted to determine whether:

  (i) The programs have been implemented in accordance with written hospital policy;

  (ii) The programs are effective in meeting stated goals;

  (iii) Improvements or modifications have been made to increase the effectiveness of program design.

  (12) Applicability to Inpatient Psychiatric Care and Inpatient Rehabilitation Services.

  (a) Provisions in the Hospital Utilization Review Program also apply to inpatient psychiatric care and inpatient rehabilitation services.