37.106.1821 SPECIALTY MENTAL HEALTH FACILITY: UTILIZATION REVIEW
(1) A specialty mental health facility must have in effect a utilization review plan to review services furnished by the facility to patients, either through contracted services or by members of its medical staff to patients, in order to determine through semi-annual review, whether utilization of services was appropriate, established policies were followed, and any changes are needed.
(2) Such a review mechanism shall consider, during each semi-annual review period, at least the following:
(a) the utilization of facility services, including at least the number of patients served and the volume of services;
(b) sample facility cases consisting of not less than 10% of both active and closed patient records;
(c) review of the sample cases to determine the medical necessity of the medical and professional services furnished, including drugs and biologicals; and
(d) the facility's health care policies.