For hospitals that use Joint Commission accreditation for deemed status purposes:

(1)

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a utilization review plan that provides for review of services provided by the hospital and the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. Note: The hospital does not need to have a utilization review plan if either a quality improvement organization has assumed binding review for the hospital or the Centers for Medicare & Medicaid Services has determined that the utilization review procedures established by the state under title XIX of the Social Security Act are superior to the procedures required in this section, and has required hospitals in that state to meet the utilization review plan requirements under 42 CFR 456.50 through 42 CFR 456.245.

(2)

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital’s utilization review plan provides for the review of Medicare and Medicaid patients with respect to the medical necessity of the following: - Admissions to the hospital - Duration of stays - Professional services provided, including drugs and biologicals Note 1: The hospital may perform reviews of admissions before, during, or after hospital admission. Note 2: The hospital may perform reviews on a sample basis, except for reviews of extended stay cases.

(3)

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a utilization review committee that is either a staff committee or a group outside the hospital established by the local medical society and some or all the hospitals in the locality or in a manner approved by the Centers for Medicare & Medicaid Services. Note: If, because of the small size of the hospital, it is impracticable to have a properly functioning staff committee, the utilization review committee is established by a group outside the hospital, as specified in 42 CFR 482.30(b)(1) (ii).

(4)

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital’s utilization review committee consists of two or more licensed practitioners, and at least two of the members of the committee are doctors of medicine or osteopathy. The other members may be any of the other types of practitioners specified in 42 CFR 482.12(c)(1). Note: The committee or group’s reviews are not conducted by any individual who has a direct financial interest (for example, an ownership interest) in that hospital or who was professionally involved in the care of the patient whose case is being reviewed. (See also MS.16.01.03, EP 5)

(5)

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital’s utilization review committee reviews professional services provided to determine medical necessity and to promote the most efficient use of available health facilities and services.

(6)

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital develops and implements a process to determine if an admission or continued stay is not medically necessary. This determination is made by one of the following: - One member of the utilization review committee if the licensed practitioner(s) responsible for the patient’s care, as specified in 42 CFR 482.12(c), concurs with the determination or fails to present their views when afforded the opportunity - At least two members of the utilization review committee in all other cases Note: Before determining that an admission or continued stay is not medically necessary, the utilization review committee consults the licensed practitioner(s) responsible for the patient’s care, as specified in 42 CFR 482.12(c), and affords the practitioner(s) the opportunity to present their views.

(7)

For hospitals that use Joint Commission accreditation for deemed status purposes: If the hospital is paid for inpatient hospital services under the prospective payment system set forth in 42 CFR Part 412, it conducts a review of duration of stays and a review of professional services as follows: - For duration of stays, the hospital reviews only cases that it determines to be outlier cases based on extended length of stay, as described in 42 CFR 412.80(a)(1)(i). - For professional services, the hospital reviews only cases that it determines to be outlier cases based on extraordinarily high costs, as described in 42 CFR 412.80(a)(1)(ii).

(8)

For hospitals that use Joint Commission accreditation for deemed status purposes: In hospitals that are not paid under the prospective payment system, the utilization review (UR) committee periodically reviews, as specified in the UR plan, each current inpatient during a continuous period of extended duration. The scheduling of the periodic reviews may be the same for all cases or differ for different classes of cases. Note: The UR committee conducts its review no later than seven days after the day required in the UR plan.

(9)

For hospitals that use Joint Commission accreditation for deemed status purposes: In hospitals paid under the prospective payment system, the utilization review (UR) committee reviews all cases where the extended length of stay exceeds the threshold criteria for the diagnosis, as described in 42 CFR 412.80 (a)(1)(i). The hospital is not required to review an extended stay that does not exceed the outlier threshold for the diagnosis. Note: The UR committee conducts its review no later than seven days after the day required in the UR plan.

(10)

For hospitals that use Joint Commission accreditation for deemed status purposes: If the utilization review committee determines that admission to or continued stay in the hospital is not medically necessary, the committee gives written notification to the hospital, the patient, and the licensed practitioner(s) responsible for the patient’s care, as specified in 42 CFR 482.12(c), no later than two days after the determination.