CMS SOM App. A, Tag A-0656

Stays

(1) The determination that an admission or continued stay is not medically necessary-

(i) May be made by one member of the UR committee if the practitioner or

practitioners responsible for the care of the patient, as specified of §482.12(c),

concur with the determination or fail to present their views when afforded the

opportunity; and

(ii) Must be made by at least two members of the UR committee in all other cases.

(2) Before making a determination that an admission or continued stay is not

medically necessary, the UR committee must consult the practitioner or practitioners

responsible for the care of the patient, as specified in §482.12(c), and afford the

practitioner or practitioners the opportunity to present their views.

(3) If the committee decides that admission to or continued stay in the hospital is not

medically necessary, written notification must be given, no later than 2 days after the

determination, to the hospital, the patient, and the practitioner or practitioners

responsible for the care of the patient, as specified in §482.12(c);

Interpretive Guidelines §482.30(d)

When other than a doctor of medicine or osteopathy makes an initial finding that the written

criteria for extended stay are not met, the case must be referred to the committee, or subgroup

thereof which contains at least one physician. If the committee or subgroup agrees after

reviewing the case that admissions, or extended stay is not medically necessary or appropriate,

the attending physician is notified and allowed an opportunity to present his views and any

additional information relating to the patient’s needs for admissions or extended stay. When a

physician member of the committee performs the initial review instead of a non-physician

reviewer, and he finds that admissions or extended stay is not necessary no referral to the

committee or subgroup is necessary and he may notify the attending practitioner directly.

If the attending practitioner does not respond or does not contest the findings of the committee or

subgroup or those of the physician who performed the initial review, then the findings are final.

If the attending physician contests the committee or subgroup findings, or if he presents

additional information relating to the patient’s need for extended stay, at least one additional

physician member of the committee must review the case. If the two physician members

determine that the patient’s stay is not medically necessary or appropriate after considering all

the evidence, their determination becomes final. Written notification of this decision must be

sent to the attending physician, patient (or next of kin), facility administrator, and the single State

agency (in the case of Medicaid) no later than 2 days after such final decision and in no event

later than 3 working days after the end of the assigned extended stay period.

There are only 5 working days in a given week. Normally these days are Monday through

Friday, however, the institution has the option to establish 5 other days as working days. When a

holiday falls on a working day, that day is not counted as a working day.

In no case may a non-physician make a final determination that a patient’s stay is not medically

necessary or appropriate.

If, after referral of a questioned case to the committee or subgroup thereof, the physician

reviewer determines that an admission or extended stay is justified, the attending physician shall

be so notified and an appropriate date for subsequent extended stay review will be selected and

noted on the patient’s record.

Written notification of this final determination must be sent to the attending physician, the

patient (or next of kin), the facility administrator and the single State agency (in the case of

Medicaid) no later than 2 days after such final determination and in no event later than 3 working

days after the end of the assigned extended stay period.

Where possible, the written notification should be received by all involved parties within the

stated time period. Where appropriate and desired, verbal notification may precede written

notification.

Survey Procedures §482.30(d)

• Review a sample of “medically unnecessary” decisions involving admissions or

continued stay that are not medically necessary and determine that these decisions are

made by:

o One member of the UR committee, if the practitioner(s) responsible for the patient’s

care concurs with the determination or fails to present his/her views. The practitioner

must be one of those specified in §482.12(c), or

o At least two members of the UR committee in all cases not qualified under the above.

• Review a sample of “medically unnecessary” decisions and verify that the physician or

practitioners, as specified in §482.12(c), were informed of the committees expected

decision and were given an opportunity to comment.

• Review a sample of “medically unnecessary” cases and verify that all involved parties are

notified of the decision that care is medically not necessary no later than two days

following the decision.