DAR File No. 43833

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-1-12

Utilization Review

Notice of Proposed Rule

(Amendment)

DAR File No.: 43833
Filed: 06/28/2019 12:25:39 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of these changes are to implement, by rule, Medicaid policy as it relates to utilization review of hospital services.

Summary of the rule or change:

These amendments update and clarify utilization review of hospital services, and remove criteria that defers to Rule R414-2B. (EDITOR'S NOTE: The proposed repeal of Rule R414-2B is under Filing No. 43835 in the issue, July 15, 2019, of the Bulletin.)

Statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because these changes only update and clarify policy for utilization review. They do not affect member services nor provider reimbursement.

local governments:

There is no impact on local governments because they neither fund nor provide utilization review under the Medicaid program.

small businesses:

There is no impact on small businesses because these changes only update and clarify policy for utilization review. They do not affect member services nor provider reimbursement.

persons other than small businesses, businesses, or local governmental entities:

There is no impact on Medicaid providers and Medicaid members because these changes only update and clarify policy for utilization review. They do not affect member services nor provider reimbursement.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid member because these changes only update and clarify policy for utilization review. They do not affect member services nor provider reimbursement.

Comments by the department head on the fiscal impact the rule may have on businesses:

After conducting a thorough analysis, it was determined that these proposed rule changes will not result in a fiscal impact on businesses.

Joseph K. Miner, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

08/14/2019

This rule may become effective on:

08/21/2019

Authorized by:

Joseph Miner, Executive Director

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs	FY 2020	FY 2021	FY 2022
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Person	$0	$0	$0
Total Fiscal Costs:	$0	$0	$0
Fiscal Benefits
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Persons	$0	$0	$0
Total Fiscal Benefits:	$0	$0	$0
Net Fiscal Benefits:	$0	$0	$0

 

*This table only includes fiscal impacts that could be measured. If there are inestimable fiscal impacts, they will not be included in this table. Inestimable impacts for State Government, Local Government, Small Businesses and Other Persons are described in the narrative. Inestimable impacts for Non - Small Businesses are described in Appendix 2.

 

Appendix 2: Regulatory Impact to Non - Small Businesses

None of the 113 non-small business providers will be impacted because this rule only implements current Medicaid policy for inpatient hospital services. It neither affects member services nor provider reimbursement.

 

 

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-1. Utah Medicaid Program.

R414-1-12. Utilization Review.

(1) The Department conducts hospital utilization review as outlined in the Hospital Services Utah Medicaid Provider Manual in effect at the time service is rendered.

(2) The Department shall determine medical necessity and appropriateness of inpatient admissions [during utilization review by use of InterQual Criteria, published by McKesson Corporation]through the use of evidence-based criteria.

(3) The standards in [the InterQual Criteria]any evidence-based criteria shall not apply to services in which a determination has been made to utilize criteria customized by the Department or that are:

(a) excluded as a Medicaid benefit by rule or contract;[

(b) provided in an intensive physical rehabilitation center as described in Rule R414-2B;] or

([c]b) organ transplant services as described in Rule R414-10A.

In these exceptions, or where [InterQual]evidence-based criteria is silent, the Department shall approve or deny services based upon appropriate administrative rules or its own criteria as incorporated in the Medicaid provider manuals.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [May 8, 2018]2019

Notice of Continuation: February 15, 2017

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 26-34-2