105. Mass. Code Regs. 150.014. - Utilization Review

“Utilization Review”
 
This section establishes that facilities, which provide Level I or II caremust review the services, quality of care and utilization of their facilities as detailed in this section. The utilization review process must include a review of all or a sample of patients to determine appropriateness of admissions, duration of stays by level of care, professional services and other relevant aspects of care and services provided by the facility. A member that has a proprietary interest in the facility cannot conduct this review. Medical care evaluation reviews (special studies) can use statistical services, fiscal intermediaries, the facility's records and other such sources to obtain data needed to perform these studies. To facilitate review, the utilization review committee must use the complete medical record or a summary of the record and use such methods as a utilization review check list and interviews with the attending physicians or physician-physician assistant teams or physician-nurse practitioner teams as indicated.The facility must have in effect a currently applicable written plan for utilization review, which applies to all patients in the facility, and a copy of the current plan must be filed with the Department.The administration must also provide support and assistance to the utilization review committee in: assembling information, facilitating chart reviews, conducting studies, exploring ways to improve procedures, maintaining committee records, promoting the most efficient use of available health services and facilities and in planning for the patient's continuity of care upon discharge.