HOSPITAL TRANSMITTAL FOR DAY OUTLIER REQUEST PATIENT NAME-(Last, First) ADMISSION DATE In order to facilitate the review of day outliers, the hospital must check () below that the required documents are included with the outlier request being submitted to the Department. I A. APPROPRIATE ADMISSION CERTIFICATION/OUTLIER REQUEST FORM I 1. Elective Admissions a. A copy of the "Place of Service Review Notice" *Note: "Requested Outlier Days" must be completed � OR � b. A "Day Outlier Request for Cases Exempt from the PSR/DRG Process" form *NOTE: Item 2 must be completed (outlier days requested). I 2. Urgent or Emergency Admissions a. A copy of the "DRG/CHR Certification Notice" *Note: "Requested Outlier Days" must be completed � OR � b. A "Day Outlier Request for Cases Exempt from the PSR/DRG Process" form *NOTE: Item 2 must be completed (outlier days requested). I I I I B. HOSPITAL CLAIM ADJUSTMENT OR INVOICE *Note: Must be original and on one page C. COPY OF REMITTANCE ADVICE SHOWING EITHER THE BASE DRG PAYMENT OR THE MOST RECENT INTERIM BILL PAYMENT D. HOSPITAL UTILIZATION REVIEW COMMITTEE COMMENTS ON HOSPITAL LETTERHEAD STATIONARY E. COPY OF COMPLETE INPATIENT MEDICAL RECORD All documents for this case, including the final claim adjustment or invoice and this transmittal, should be securely packaged and mailed to: Department of Public Welfare Division of Medical Review DRG Outlier Review Section PO Box 8171 Harrisburg, PA 17105-8171 or overnight to: DPW - Division of Medical Review DRG Outlier Review Section DGS Annex Complex Cherrywood Building #33 Beech Drive Harrisburg, PA 17110 Without the complete documentation, the Division of Medical Review cannot review your outlier request in a timely manner. NAME OF HOSPITAL PERSON TO CONTACT ON THIS REQUEST TELEPHONE NUMBER HOSPITAL NAME American LegalNet, Inc. www.FormsWorkFlow.com MA 116 9/06