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42 C.F.R. PART 456--UTILIZATION CONTROL

TITLE 42--Public Health

CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

SUBCHAPTER C--MEDICAL ASSISTANCE PROGRAMS

PART 456--UTILIZATION CONTROL

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.

�456.60

Certification and recertification of need for inpatient care.

�456.80

Individual written plan of care.

�456.100

Scope.

�456.101

UR plan required for inpatient hospital services.

�456.105

UR committee required.

�456.106

Organization and composition of UR committee; disqualification from UR committee membership.

�456.111

Recipient information required for UR.

�456.112

Records and reports.

�456.113

Confidentiality.

�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.

�456.131

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

stay review process.

�456.136

Notification of adverse decision.

�456.137

Time limits for final decision and notification of adverse decision.

�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.

�456.160

Certification and recertification of need for inpatient care.

�456.170

Medical, psychiatric, and social evaluations.

�456.171

Medicaid agency review of need for admission.

�456.180

Individual written plan of care.

�456.181

Reports of evaluations and plans of care.

�456.200

Scope.

�456.201

UR plan required for inpatient mental hospital services.

�456.205

UR committee required.

�456.206

Organization and composition of UR committee; disqualification from UR committee membership.

�456.211

Recipient information required for UR.

�456.212

Records and reports.

�456.213

Confidentiality.

�456.231

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

stay review process.

�456.237

Notification of adverse decision.

�456.238

Time limits for final decision and notification of adverse decision.

�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.

�456.360

Certification and recertification of need for inpatient care.

�456.370

Medical, psychological, and social evaluations.

�456.371

Exploration of alternative services.

�456.372

Medicaid agency review of need for admission.

�456.380

Individual written plan of care.

�456.381

Reports of evaluations and plans of care.

�456.400

Scope.

�456.401

State plan UR requirements and options; UR plan required for intermediate care facility services.

�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.

�456.411

Recipient information required for UR.

�456.412

Records and reports.

�456.413

Confidentiality.

�456.431

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

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.

�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.

�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 recipients.

�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 recipients 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.