2010 New York Code
PBH - Public Health
Article 28 - (2800 - 2822) HOSPITALS
2803-I - General hospital inpatient discharge review program.

§  2803-i.  General  hospital inpatient discharge review program. 1. A
  general hospital inpatient discharge review program  applicable  to  all
  patients  other  than beneficiaries of title XVIII of the federal social
  security act (medicare) shall be established  in  accordance  with  this
  section. No general hospital inpatient subject to the provisions of this
  section  may  be discharged on the basis that inpatient hospital service
  in a general hospital is no  longer  medically  necessary  and  that  an
  appropriate  discharge plan has been established unless a written notice
  of such determinations and a  copy  of  the  discharge  plan  have  been
  provided  to the patient or the appointed personal representative of the
  patient. The patient or the appointed  personal  representative  of  the
  patient  shall have the opportunity to sign the notice and a copy of the
  discharge plan and receive  a  copy  of  both  signed  documents.  Every
  general hospital shall use a common notice developed and disseminated in
  accordance  with  rules  and  regulations  adopted  by  the  council and
  approved by the commissioner which shall indicate that the patient is to
  be discharged, shall state the reasons therefor and shall state that the
  patient may request a review of such determinations. The patient, or the
  appointed personal representative of the patient may request a review of
  such determinations by the appropriate independent  professional  review
  agent  (or  "review  agent") in accordance with subdivision four of this
  section. Notwithstanding  that  the  patient  discharge  review  process
  provided  in  accordance  with federal law and regulation shall apply to
  beneficiaries  of  title  XVIII  of  the  federal  social  security  act
  (medicare),  a  written copy of the discharge plan, and discharge notice
  shall  be  provided  to  the  beneficiary  or  the  appointed   personal
  representative  of  the  beneficiary.  The  beneficiary or the appointed
  personal representative of the beneficiary shall have the opportunity to
  sign the documents and receive a copy of the signed documents.
    2. (a) For  patients  eligible  for  payments  by  state  governmental
  agencies  for  general  hospital  inpatient  services  as  the patient's
  primary payor, an independent professional review agent shall  mean  the
  commissioner  or  his designee. In conducting general hospital inpatient
  discharge reviews in accordance with this section, the commissioner  may
  utilize  the  services  of  department  personnel  or  other  authorized
  representatives, including a review agent approved  in  accordance  with
  paragraph (b) of this subdivision.
    (b)  For  patients  who  are  not  beneficiaries of title XVIII of the
  federal social security act (medicare)  nor  eligible  for  payments  by
  state   governmental   agencies  as  the  patient's  primary  payor,  an
  independent professional review agent shall mean a third party payor  of
  hospital  services  or other corporation approved by the commissioner in
  writing for purposes of conducting general hospital inpatient  discharge
  reviews  in  accordance  with  this  section. For a third party payor of
  hospital services or other corporation to be approved as an  independent
  professional  review agent in accordance with this paragraph, such third
  party payor or other corporation must meet the following  criteria:  (i)
  the  review  agent  shall  employ  or  otherwise  secure the services of
  adequate medical personnel  qualified  to  determine  the  necessity  of
  continued   inpatient  hospital  services  and  the  appropriateness  of
  hospital discharge plans; (ii) the review agent  shall  demonstrate  the
  ability  to  render  review  decisions in a timely manner as provided in
  this section; (iii) the review agent shall agree to provide ready access
  by the commissioner to all data, records and information it collects and
  maintains concerning its review activities under this section; (iv)  the
  review  agent  shall  agree  to  provide  to the commissioner such data,
  information and reports as  the  commissioner  determines  necessary  to
  evaluate  the  review process provided pursuant to this section; (v) the

review agent shall provide assurances that review  personnel  shall  not
  have  a  conflict  of  interest  in  conducting a discharge review for a
  patient based on hospital or  professional  affiliation;  and  (vi)  the
  review  agent  meets  such  other  performance  and  efficiency criteria
  regarding the conduct of reviews pursuant to this section established by
  the  commissioner.  The  commissioner  may  withdraw  approval   of   an
  independent  professional  review agent where such review agent fails to
  continue  to  meet  approval  criteria  established  pursuant  to   this
  paragraph.
    (c)  (i)  Each general hospital shall enter into contracts with one or
  more independent professional review agents approved by the commissioner
  in accordance with paragraph (b) of this  subdivision  for  purposes  of
  conducting  general  hospital  inpatient discharge reviews in accordance
  with this section for patients, including uncompensated  care  patients,
  who  are not beneficiaries of title XVIII of the federal social security
  act (medicare) nor eligible for payments by state governmental  agencies
  as  the  patients' primary payor; provided, however, a payor of hospital
  service included in the payor categories specified in paragraph  (a)  of
  subdivision one of section twenty-eight hundred seven-c of this article,
  other  than  state governmental agencies, may designate the review agent
  for their subscribers or beneficiaries or  enrolled  members  and  shall
  reimburse such designated review agent for costs of the discharge review
  program.
    (ii)  Notwithstanding  any  inconsistent  provision  of  law,  general
  hospital contract costs incurred in accordance with subparagraph (i)  of
  this  paragraph  may  be  included  as  an additional charge for general
  hospital inpatient services in determining patient  charges  for  payors
  included   in  the  payor  categories  specified  in  paragraph  (c)  of
  subdivision one of section twenty-eight hundred seven-c of this article,
  or as a charge in addition to rates  of  payment  for  general  hospital
  inpatient services in determining payment due for payors included in the
  payor  categories  specified  in  paragraph  (b)  of  subdivision one of
  section twenty-eight hundred seven-c of this article, or  paragraph  (a)
  of such subdivision one if a payor has not designated a review agent for
  such  payor's  subscribers  or  beneficiaries  or  enrolled  members, or
  paragraph (a) or (b) of subdivision two of section twenty-eight  hundred
  seven-c of this article. Such additional charges shall not be subject to
  maximum charge or rate of payment ceilings determined in accordance with
  section twenty-eight hundred seven-c of this article for such payors.
    3.  (a)  If  a general hospital and the attending physician agree that
  inpatient hospital service in a general hospital is no longer  medically
  necessary  for a patient, other than a beneficiary of title XVIII of the
  federal social security act (medicare),  and  an  appropriate  discharge
  plan  has  been  established for such patient, at that time the hospital
  shall provide the patient or the appointed  personal  representative  of
  the  patient with a written discharge notice and a copy of the discharge
  plan, meeting the requirements of subdivision one of this section.
    (b) If a general  hospital  has  determined  that  inpatient  hospital
  service  in  a  general  hospital is no longer medically necessary for a
  patient, other than a beneficiary of title XVIII of the  federal  social
  security  act  (medicare),  and  an  appropriate discharge plan has been
  established for such patient but the attending physician has not  agreed
  with   the  hospital's  determinations,  the  hospital  may  request  by
  telephone a review of the validity of the hospital's  determinations  by
  the appropriate independent professional review agent. Such review agent
  shall conduct a review of the hospital's determinations and prior to the
  conclusion  of  the  review shall provide an opportunity to the treating
  physician and an appropriate representative of the  hospital  to  confer

and provide information which may include the patient's clinical records
  if  requested  by  the  review agent. Such review agent shall notify the
  hospital of the results of its review not later  than  one  working  day
  after  the  date  the review agent has received the request, the records
  required to conduct such review, and the date  of  such  conferring  and
  receipt  of  any  additional  information  requested. The hospital shall
  provide notice to the attending physician of the results of the  review.
  If  the  review  agent  concurs  with the hospital's determinations, the
  hospital  shall  provide  the  patient   or   his   appointed   personal
  representative  with  a written notice of such determinations and notice
  that the patient shall be financially responsible  for  continued  stay,
  and  with  a  copy  of  the  proposed discharge plan. The patient or the
  appointed  personal  representative  of  the  patient  shall  have   the
  opportunity to sign the notice and a copy of the proposed discharge plan
  and  receive  a  copy  of both signed documents.  Every general hospital
  shall use a common notice developed and disseminated in accordance  with
  rules  and  regulations  adopted  by  the  council  and  approved by the
  commissioner which shall indicate the determinations made,  shall  state
  the  reasons  therefor  and  that  the patient's attending physician has
  disagreed and shall state that the patient  or  the  appointed  personal
  representative   of   the   patient   may   request  a  review  of  such
  determinations by the appropriate review agent.
    4. A  patient  in  a  general  hospital,  or  the  appointed  personal
  representative  of  the  patient,  who  receives  a  written  notice  in
  accordance with paragraph (a)  or  (b)  of  subdivision  three  of  this
  section,  may  request  a  review by the appropriate review agent of the
  determinations set forth in such notice related to medical necessity  of
  continued   inpatient  hospital  service,  the  appropriateness  of  the
  discharge plan and the availability of required continuing  health  care
  services.
    (a)  If  a  patient  while  still  hospitalized  or while no longer an
  inpatient, or the appointed personal  representative  of  such  patient,
  requests  a  review  by the appropriate review agent, the hospital shall
  promptly provide to the review agent the records required to review  the
  determinations.  Such request for a patient no longer an inpatient shall
  take place no later than thirty days after receipt of a notice  provided
  in accordance with subdivision three of this section or seven days after
  receipt  of  a  complete  bill  for  all  inpatient  services  rendered,
  whichever is later. The review agent shall  conduct  a  review  of  such
  determinations   and   shall  provide  the  treating  physician  and  an
  appropriate representative of the hospital with an opportunity to confer
  and provide information prior to  the  conclusion  of  the  review.  The
  review  agent  shall  provide  written  notice  to  the  patient, or the
  appointed personal representative of the patient, and  the  hospital  of
  the  results  of  the review within three working days of receipt of the
  requests  for  review  and  the   records   required   to   review   the
  determinations.  The  hospital  shall  provide  notice  to the attending
  physician of the results of the review.
    (b)  Notwithstanding  the  provisions  of  paragraph   (a)   of   this
  subdivision,  if  a  patient  while  still  an  inpatient in the general
  hospital, or the  appointed  personal  representative  of  the  patient,
  requests a review by the appropriate review agent not later than noon of
  the  first  working  day  after  the  date the patient, or the appointed
  personal representative of the patient, receives the written notice, the
  hospital shall provide to  the  appropriate  review  agent  the  records
  required  to  review the determinations by the close of business of such
  working day. The appropriate review agent shall conduct a review of such
  determinations and  provide  written  notice  to  the  patient,  or  the

appointed  personal  representative  of the patient, and the hospital of
  the results of the review not later than one full working day after  the
  date  the  review  agent  has  received  the request for review and such
  records. The hospital shall provide notice to the attending physician of
  the results of the review.
    5.   Notwithstanding   any  inconsistent  provision  of  law,  if  the
  appropriate  review  agent,  upon  any  review  conducted  pursuant   to
  paragraph  (b)  of  subdivision three or pursuant to subdivision four of
  this section does not concur in the determinations, continued stay in  a
  general  hospital  shall  be  deemed  necessary  and appropriate for the
  patient for purposes of payment for such continued  stay  in  accordance
  with section twenty-eight hundred seven-c of this article.
    6.  If  a patient eligible for payment for inpatient hospital services
  under a case based payment per discharge determined in  accordance  with
  section  twenty-eight  hundred seven-c of this article, or the appointed
  personal representative  of  the  patient,  requests  a  review  by  the
  appropriate review agent in accordance with paragraph (b) of subdivision
  four of this section, the hospital may not demand or request any payment
  for  additional  inpatient  hospital  services  provided to such patient
  subsequent to the proposed time of discharge and prior to  noon  of  the
  day  after the date the patient or the appointed personal representative
  of the patient receives notice of the  results  of  the  review  by  the
  review  agent  other  than payment determined in accordance with section
  twenty-eight  hundred  seven-c  of   this   article   and   deductibles,
  copayments,  or other charges that would be authorized for a patient for
  whom inpatient hospital services in a general hospital  continue  to  be
  necessary and appropriate.
    7.  In  any  review conducted pursuant to paragraph (b) of subdivision
  three or pursuant to subdivision four of this section, the review  agent
  shall  solicit  the  views  of  the  patient  involved, or the appointed
  personal representative of the patient, and the attending physician.
    8. Each patient, or  the  appointed  personal  representative  of  the
  patient,  provided  a  notice  by  a general hospital in accordance with
  subdivision three of this section shall be provided at such time by  the
  hospital with a notice, in a form developed in accordance with rules and
  regulations  adopted by the council and approved by the commissioner, of
  such patient's right to request a discharge review  in  accordance  with
  this  section.   The patient or the appointed personal representative of
  the patient shall have the opportunity to sign this form and  receive  a
  copy of the signed form.
    9.  The  council  shall  adopt  rules  and regulations, subject to the
  approval of the commissioner, necessary to implement this section.