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Title 42 → Chapter IV → Subchapter C → Part 456

TITLE 42—Public Health

CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED)

SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS

PART 456—UTILIZATION CONTROL

rule

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.
rule

Subpart B—UTILIZATION CONTROL: ALL MEDICAID SERVICES

§456.21
Scope.
§456.22
Sample basis evaluation of services.
§456.23
Post-payment review process.
rule

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

§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.
rule

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.
rule

Subpart E—[RESERVED]

rule

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.
rule

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.
rule

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.
rule

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.
rule

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.
rule

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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