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Home Page > Executive Branch > Code of Federal Regulations > Electronic Code of Federal Regulations
e-CFR Data is current as of February 4, 2010
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
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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
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| Certification and recertification of need for inpatient care. |
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| Individual written plan of care. |
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| UR plan required for inpatient hospital services. |
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| Organization and composition of UR committee; disqualification from UR committee membership. |
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| Recipient information required for UR. |
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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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| 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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| Notification of adverse decision. |
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| Time limits for final decision and notification of adverse decision. |
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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
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| Certification and recertification of need for inpatient care. |
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| Medical, psychiatric, and social evaluations. |
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| Medicaid agency review of need for admission. |
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| Individual written plan of care. |
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| Reports of evaluations and plans of care. |
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| UR plan required for inpatient mental hospital services. |
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| Organization and composition of UR committee; disqualification from UR committee membership. |
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| Recipient information required for UR. |
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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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| Notification of adverse decision. |
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| Time limits for final decision and notification of adverse decision. |
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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
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| Certification and recertification of need for inpatient care. |
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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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| Individual written plan of care. |
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| Reports of evaluations and plans of care. |
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| State plan UR requirements and options; UR plan required for intermediate care facility services. |
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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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| Recipient information required for UR. |
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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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| 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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| Waiver options for Medicaid agency. |
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| Review and granting of waiver requests. |
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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 recipients. |
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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 recipients 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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