e-CFR data is current as of March 4, 2021
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
Subpart A—GENERAL PROVISIONS
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Basis and purpose of part. |
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Statewide surveillance and utilization control program. |
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Responsibility for monitoring the utilization control program. |
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Review by State medical agency of appropriateness and quality of services. |
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Subpart B—UTILIZATION CONTROL: ALL MEDICAID SERVICES
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Sample basis evaluation of services. |
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Post-payment review process. |
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Subpart C—UTILIZATION CONTROL: HOSPITALS
Certification of Need for Care
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Certification and recertification of need for inpatient care. |
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Plan of Care
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Individual written plan of care. |
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Utilization Review (UR) Plan: General Requirement
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UR plan required for inpatient hospital services. |
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UR Plan: Administrative Requirements
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Organization and composition of UR committee; disqualification from UR committee membership. |
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UR Plan: Informational Requirements
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Beneficiary information required for UR. |
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UR Plan: Review of Need for Admission
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Admission review required. |
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Evaluation criteria for admission review. |
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Admission review process. |
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Notification of adverse decision. |
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Time limits for admission review. |
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Time limits for final decision and notification of adverse decision. |
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Initial continued stay review date. |
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Description of methods and criteria: Initial continued stay review date; close professional scrutiny; length of stay modification. |
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UR Plan: Review of Need for Continued Stay
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Continued stay review required. |
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Evaluation criteria for continued stay. |
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Subsequent continued stay review dates. |
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Description of methods and criteria: Subsequent continued stay review dates; length of stay modification. |
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Continued stay review process. |
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Notification of adverse decision. |
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Time limits for final decision and notification of adverse decision. |
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UR Plan: Medical Care Evaluation Studies
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Purpose and general description. |
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UR plan requirements for medical care evaluation studies. |
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Content of medical care evaluation studies. |
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Data sources for studies. |
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Number of studies required to be performed. |
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Subpart D—UTILIZATION CONTROL: MENTAL HOSPITALS
Certification of Need for Care
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Certification and recertification of need for inpatient care. |
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Medical, Psychiatric, and Social Evaluations and Admission Review
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Medical, psychiatric, and social evaluations. |
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Plan of Care
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Individual written plan of care. |
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Reports of evaluations and plans of care. |
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Utilization Review (UR) Plan: General Requirements
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UR plan required for inpatient mental hospital services. |
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UR Plan: Administrative Requirements
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Organization and composition of UR committee; disqualification from UR committee membership. |
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UR Plan: Informational Requirements
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Beneficiary information required for UR. |
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UR Plan: Review of Need for Continued Stay
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Continued stay review required. |
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Evaluation criteria for continued stay. |
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Initial continued stay review date. |
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Subsequent continued stay review dates. |
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Description of methods and criteria: Continued stay review dates; length of stay modification. |
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Continued stay review process. |
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Notification of adverse decision. |
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Time limits for final decision and notification of adverse decision. |
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UR Plan: Medical Care Evaluation Studies
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Purpose and general description. |
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UR plan requirements for medical care evaluation studies. |
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Content of medical care evaluation studies. |
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Data sources for studies. |
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Number of studies required to be performed. |
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Subpart E—[RESERVED]
Subpart F—UTILIZATION CONTROL: INTERMEDIATE CARE FACILITIES
Certification of Need for Care
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Certification and recertification of need for inpatient care. |
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Medical, Psychological, and Social Evaluations and Admission Review
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Medical, psychological, and social evaluations. |
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Exploration of alternative services. |
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Medicaid agency review of need for admission. |
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Plan of Care
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Individual written plan of care. |
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Reports of evaluations and plans of care. |
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Utilization Review (UR) Plan: General Requirement
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State plan UR requirements and options; UR plan required for intermediate care facility services. |
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UR Plan: Administrative Requirements
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Description of UR review function: How and when. |
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Description of UR review function: Who performs UR; disqualification from performing UR. |
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UR responsibilities of administrative staff. |
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UR Plan: Informational Requirements
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Beneficiary information required for UR. |
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UR Plan: Review of Need for Continued Stay
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Continued stay review required. |
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Evaluation criteria for continued stay. |
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Initial continued stay review date. |
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Subsequent continued stay review dates. |
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Description of methods and criteria: Continued stay review dates. |
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Continued stay review process. |
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Notification of adverse decision. |
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Time limits for notification of adverse decision. |
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Subpart G—INPATIENT PSYCHIATRIC SERVICES FOR INDIVIDUALS UNDER AGE 21: ADMISSION AND PLAN OF CARE REQUIREMENTS
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Admission certification and plan of care. |
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Medical, psychiatric, and social evaluations. |
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Subpart H—UTILIZATION REVIEW PLANS: FFP, WAIVERS, AND VARIANCES FOR HOSPITALS AND MENTAL HOSPITALS
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UR plans as a condition for FFP. |
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UR Plan: Waiver of Requirements
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Waiver options for Medicaid agency. |
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Review and granting of waiver requests. |
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UR Plan: Remote Facility Variances from Time Requirements
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Conditions for granting variance requests. |
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Content of request for variance. |
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Notification of Administrator's action and duration of variance. |
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Request for renewal of variance. |
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Subpart I—INSPECTIONS OF CARE IN INTERMEDIATE CARE FACILITIES AND INSTITUTIONS FOR MENTAL DISEASES
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Financial interests and employment of team members. |
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Physician team member inspecting care of beneficiaries. |
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Number and location of teams. |
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Frequency of inspections. |
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Notification before inspection. |
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Personal contact with and observation of beneficiaries and review of records. |
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Basis for determinations. |
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Inspections by utilization review committee. |
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Subpart J—PENALTY FOR FAILURE TO MAKE A SATISFACTORY SHOWING OF AN EFFECTIVE INSTITUTIONAL UTILIZATION CONTROL PROGRAM
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Basis, purpose and scope. |
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Requirements for an effective utilization control program. |
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Acceptable reasons for not meeting requirements for annual on-site review. |
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Requirements for content of showings and procedures for submittal. |
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Computation of reductions in FFP. |
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Subpart K—DRUG USE REVIEW (DUR) PROGRAM AND ELECTRONIC CLAIMS MANAGEMENT SYSTEM FOR OUTPATIENT DRUG CLAIMS
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Retrospective drug use review. |
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DUR/surveillance and utilization review relationship. |
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Electronic claims management system. |
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