42 CFR Part 456
PART 456—UTILIZATION CONTROL
- PART 456—UTILIZATION CONTROL
- Chapter IV—Centers for Medicare & Medicaid Services, Department of Health and Human Services › Subchapter C—Medical Assistance Programs
- Subpart A—General Provisions
- § 456.1 Basis and purpose of part.
- § 456.2 State plan requirements.
- § 456.3 Statewide surveillance and utilization control program.
- § 456.4 Responsibility for monitoring the utilization control program.
- § 456.5 Evaluation criteria.
- § 456.6 Review by State medical agency of appropriateness and quality of services.
- Subpart B—Utilization Control: All Medicaid Services
- § 456.21 Scope.
- § 456.22 Sample basis evaluation of services.
- § 456.23 Post-payment review process.
- Subpart C—Utilization Control: Hospitals
- § 456.50 Scope.
- § 456.51 Definitions.
- Certification of Need for Care
- § 456.60 Certification and recertification of need for inpatient care.
- Plan of Care
- § 456.80 Individual written plan of care.
- Utilization Review (UR) Plan: General Requirement
- § 456.100 Scope.
- § 456.101 UR plan required for inpatient hospital services.
- UR Plan: Administrative Requirements
- § 456.105 UR committee required.
- § 456.106 Organization and composition of UR committee; disqualification from UR committee membership.
- UR Plan: Informational Requirements
- § 456.111 Beneficiary information required for UR.
- § 456.112 Records and reports.
- § 456.113 Confidentiality.
- UR Plan: Review of Need for Admission 1
- § 456.121 Admission review required.
- § 456.122 Evaluation criteria for admission review.
- § 456.123 Admission review process.
- § 456.124 Notification of adverse decision.
- § 456.125 Time limits for admission review.
- § 456.126 Time limits for final decision and notification of adverse decision.
- § 456.127 Pre-admission review.
- § 456.128 Initial continued stay review date.
- § 456.129 Description of methods and criteria: Initial continued stay review date; close professional scrutiny; length of stay modification.
- UR Plan: Review of Need for Continued Stay
- § 456.131 Continued stay review required.
- § 456.132 Evaluation criteria for continued stay.
- § 456.133 Subsequent continued stay review dates.
- § 456.134 Description of methods and criteria: Subsequent continued stay review dates; length of stay modification.
- § 456.135 Continued stay review process.
- § 456.136 Notification of adverse decision.
- § 456.137 Time limits for final decision and notification of adverse decision.
- UR Plan: Medical Care Evaluation Studies
- § 456.141 Purpose and general description.
- § 456.142 UR plan requirements for medical care evaluation studies.
- § 456.143 Content of medical care evaluation studies.
- § 456.144 Data sources for studies.
- § 456.145 Number of studies required to be performed.
- Subpart D—Utilization Control: Mental Hospitals
- § 456.150 Scope.
- § 456.151 Definitions.
- Certification of Need for Care
- § 456.160 Certification and recertification of need for inpatient care.
- Medical, Psychiatric, and Social Evaluations and Admission Review
- § 456.170 Medical, psychiatric, and social evaluations.
- § 456.171 [Reserved]
- Plan of Care
- § 456.180 Individual written plan of care.
- § 456.181 Reports of evaluations and plans of care.
- Utilization Review (UR) Plan: General Requirements
- § 456.200 Scope.
- § 456.201 UR plan required for inpatient mental hospital services.
- UR Plan: Administrative Requirements
- § 456.205 UR committee required.
- § 456.206 Organization and composition of UR committee; disqualification from UR committee membership.
- UR Plan: Informational Requirements
- § 456.211 Beneficiary information required for UR.
- § 456.212 Records and reports.
- § 456.213 Confidentiality.
- UR Plan: Review of Need for Continued Stay
- § 456.231 Continued stay review required.
- § 456.232 Evaluation criteria for continued stay.
- § 456.233 Initial continued stay review date.
- § 456.234 Subsequent continued stay review dates.
- § 456.235 Description of methods and criteria: Continued stay review dates; length of stay modification.
- § 456.236 Continued stay review process.
- § 456.237 Notification of adverse decision.
- § 456.238 Time limits for final decision and notification of adverse decision.
- UR Plan: Medical Care Evaluation Studies
- § 456.241 Purpose and general description.
- § 456.242 UR plan requirements for medical care evaluation studies.
- § 456.243 Content of medical care evaluation studies.
- § 456.244 Data sources for studies.
- § 456.245 Number of studies required to be performed.
- Subpart E [Reserved]
- Subpart F—Utilization Control: Intermediate Care Facilities
- § 456.350 Scope.
- § 456.351 Definition.
- Certification of Need for Care
- § 456.360 Certification and recertification of need for inpatient care.
- Medical, Psychological, and Social Evaluations and Admission Review
- § 456.370 Medical, psychological, and social evaluations.
- § 456.371 Exploration of alternative services.
- § 456.372 Medicaid agency review of need for admission.
- Plan of Care
- § 456.380 Individual written plan of care.
- § 456.381 Reports of evaluations and plans of care.
- Utilization Review (UR) Plan: General Requirement
- § 456.400 Scope.
- § 456.401 State plan UR requirements and options; UR plan required for intermediate care facility services.
- UR Plan: Administrative Requirements
- § 456.405 Description of UR review function: How and when.
- § 456.406 Description of UR review function: Who performs UR; disqualification from performing UR.
- § 456.407 UR responsibilities of administrative staff.
- UR Plan: Informational Requirements
- § 456.411 Beneficiary information required for UR.
- § 456.412 Records and reports.
- § 456.413 Confidentiality.
- UR Plan: Review of Need for Continued Stay
- § 456.431 Continued stay review required.
- § 456.432 Evaluation criteria for continued stay.
- § 456.433 Initial continued stay review date.
- § 456.434 Subsequent continued stay review dates.
- § 456.435 Description of methods and criteria: Continued stay review dates.
- § 456.436 Continued stay review process.
- § 456.437 Notification of adverse decision.
- § 456.438 Time limits for notification of adverse decision.
- Subpart G—Inpatient Psychiatric Services for Individuals Under Age 21: Admission and Plan of Care Requirements
- § 456.480 Scope.
- § 456.481 Admission certification and plan of care.
- § 456.482 Medical, psychiatric, and social evaluations.
- Subpart H—Utilization Review Plans: FFP, Waivers, and Variances for Hospitals and Mental Hospitals
- § 456.500 Purpose.
- § 456.501 UR plans as a condition for FFP.
- UR Plan: Waiver of Requirements
- § 456.505 Applicability of waiver.
- § 456.506 Waiver options for Medicaid agency.
- § 456.507 Review and granting of waiver requests.
- § 456.508 Withdrawal of waiver.
- UR Plan: Remote Facility Variances from Time Requirements
- § 456.520 Definitions.
- § 456.521 Conditions for granting variance requests.
- § 456.522 Content of request for variance.
- § 456.523 Revised UR plan.
- § 456.524 Notification of Administrator's action and duration of variance.
- § 456.525 Request for renewal of variance.
- Subpart I—Inspections of Care in Intermediate Care Facilities and Institutions for Mental Diseases
- § 456.600 Purpose.
- § 456.601 Definitions.
- § 456.602 Inspection team.
- § 456.603 Financial interests and employment of team members.
- § 456.604 Physician team member inspecting care of beneficiaries.
- § 456.605 Number and location of teams.
- § 456.606 Frequency of inspections.
- § 456.607 Notification before inspection.
- § 456.608 Personal contact with and observation of beneficiaries and review of records.
- § 456.609 Determinations by team.
- § 456.610 Basis for determinations.
- § 456.611 Reports on inspections.
- § 456.612 Copies of reports.
- § 456.613 Action on reports.
- § 456.614 Inspections by utilization review committee.
- Subpart J—Penalty for Failure To Make a Satisfactory Showing of an Effective Institutional Utilization Control Program
- § 456.650 Basis, purpose and scope.
- § 456.651 Definitions.
- § 456.652 Requirements for an effective utilization control program.
- § 456.653 Acceptable reasons for not meeting requirements for annual on-site review.
- § 456.654 Requirements for content of showings and procedures for submittal.
- § 456.655 Validation of showings.
- § 456.656 Reductions in FFP.
- § 456.657 Computation of reductions in FFP.
- Subpart K—Drug Use Review (DUR) Program and Electronic Claims Management System for Outpatient Drug Claims
- § 456.700 Scope.
- § 456.702 Definitions.
- § 456.703 Drug use review program.
- § 456.705 Prospective drug review.
- § 456.709 Retrospective drug use review.
- § 456.711 Educational program.
- § 456.712 Annual report.
- § 456.714 DUR/surveillance and utilization review relationship.
- § 456.716 DUR Board.
- § 456.719 Funding for DUR program.
- § 456.722 Electronic claims management system.
- § 456.725 Funding of ECM system.
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