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37.106.1111    MEDICAL ASSISTANCE FACILITIES: UTILIZATION REVIEW

(1) A medical assistance facility must:

(a) Have in effect a utilization review plan to review services furnished by the facility and by members of its medical staff to patients.

(b) Contract with the state peer review organization (PRO) or its department approved equivalent to do the following:

(i) Certify whether all admissions to the facility in the facility's first 12 months of operation were medically necessary;

(ii) During the facility ' s first 12 months of operation provide consultation to the facility sometime between the 48th and 72nd hour of the stay of each patient admitted to the facility during that period concerning discharge plans for the patient (e.g. transfer to the hospital, discharge to a skilled nursing facility, discharge to home) ;

(iii) Periodically sample facility cases and review them to determine the medical necessity of the professional services furnished, including drugs and biologicals; during the facility's first 12 months of operation, the review must include retrospective review of 25% of the cases of patients admitted to the facility during that period.

(2) After the medical assistance facility's first 12 months of operation, the facility must collaborate and cooperate with the state PRO or its department approved equivalent, pursuant to a written agreement, in projects designed to identify and assess opportunities to improve the quality of patient care, the utilization of the facility, and the appropriateness of the discharge planning and the disposition of each of the facility's patients following treatment. Collaboration by the facility must include:

(a) Participating in the design of the projects;

(b) Providing medical records to the state PRO or its department approved equivalent for abstraction or completing the abstraction of records on site and submitting the results to the state PRO or its department approved equivalent;

(c) Assessing the results of the abstraction; and

(d) Developing plans necessary to ensure continuous improvement in the care provided to patients at the facility.

History: Sec. 50-5-103, MCA; IMP, Sec. 50-5-101, 50-5-103 and 50-5-204, MCA; NEW, 1989 MAR p. 663, Eff. 4/28/89; AMD, 1996 MAR p. 682, Eff. 3/8/96; TRANS, from DHES, 2002 MAR p. 185.

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