B. Role of State agencies in utilization review

Official source

To insure that Medicare beneficiaries receive quality care through sound utilization of institutional facilities and professional services, a utilization review plan based on statutory requirements was included as a condition of participation for hospitals and SNF’s. To assure providers are complying with the requirements of utilization review, State agencies periodically review each provider’s mechanism. However, where a PSRO is operating, the conditions of participation do not require utilization review.

The Part A intermediary also becomes concerned with such utilization review factors as the proper length of stay and the necessity of the services performed in individual cases. State agencies and intermediaries are encouraged to exchange their findings in utilization review so that they can complement each other’s efforts.

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B. Role of State agencies in utilization review

Official source

To insure that Medicare beneficiaries receive quality care through sound utilization of institutional facilities and professional services, a utilization review plan based on statutory requirements was included as a condition of participation for hospitals and SNF’s. To assure providers are complying with the requirements of utilization review, State agencies periodically review each provider’s mechanism. However, where a PSRO is operating, the conditions of participation do not require utilization review.

The Part A intermediary also becomes concerned with such utilization review factors as the proper length of stay and the necessity of the services performed in individual cases. State agencies and intermediaries are encouraged to exchange their findings in utilization review so that they can complement each other’s efforts.