Utilization Review

(A) The hospital must determine the medical or administrative necessity of each continued inpatient hospital stay of a member in accordance with the level-of-care criteria in 130 CMR 435.409 and 435.410. For those members requiring a less-than-hospital level of care, the hospital must determine the appropriate care in accordance with the MassHealth agency's medical eligibility criteria in 130 CMR 456.000. (B) The MassHealth agency may designate an agent to determine the medical or administrative necessity of each inpatient hospital stay.