Library: Policy

317:30-3-6. Utilization review for physician/hospital services

Revised 7-25-08

   The Surveillance and Utilization Review System (SURS) is used to help identify patterns of inappropriate care and services.

• (1) Use of this system enables OHCA to develop a comprehensive profile of any aberrant pattern of practice and reveals suspected instances of fraud or abuse in the SoonerCare Program.  Also, the Utilization Review program is a useful tool in detecting the existence of any potential defects in the level of care or service provided under the SoonerCare Program.

• (2) OHCA contracts with a Quality Improvement Organization (QIO) to review the length of stay and appropriateness of hospital admissions.  Unresolved patterns of non-compliance with medical criteria for admissions, outpatient procedures and length of stay will be referred to OHCA.