CMS Pub. 100-01, ch. 4, § 10.8.2

or After October 1, 1983 Under PPS

(Rev. 1, 09-11-02)

For cases subject to the prospective payment system (PPS), certification is not required at

the time of admission for inpatient services. The admission is reviewed by a hospital

review organization upon discharge of the patient. For outlier cases certification is

required as follows:

• For day-outlier cases (now discontinued), certification was required no later

than 1 day after the hospital reasonably assumes that the case meets the

established outlier criteria, or no later than 20 days into the hospital stay,

whichever is earlier. The first and subsequent recertifications are required at

intervals established by the utilization review committee, on a case-by-case

basis if it so chooses, but not less than every 30 days.

• For cost-outlier cases, if possible, certification must be made before the

hospital incurs cost for which it will seek cost outlier payment. However,

certification is required no later than the date on which the hospital requests

cost outlier payment or 20 days into the hospital stay, whichever is earlier. For

cost-outlier cases, the first and subsequent recertifications are required at

intervals established by the UR committee, on a case-by-case basis if it

chooses.

As previously stated the UR committee will be reviewing long-stay cases and may be in

the best position to decide when subsequent recertifications are needed. Review by the

UR committee used in place of recertification for PPS day outlier cases is considered

timely if performed within 7 days after the physician recertification would have been

required.