Title 42

PART 456

Part 456 - Utilization Control

PART 456 - UTILIZATION CONTROL Authority:Sec. 1102 of the Social Security Act (42 U.S.C. 1302), unless otherwise noted. Link to an amendment published at 85 FR 87104, Dec. 31, 2020. Source:43 FR 45266, Sept. 29, 1978, unless otherwise noted.

• Authority: Sec. 1102 of the Social Security Act (42 U.S.C. 1302), unless otherwise noted.
• Source: 43 FR 45266, Sept. 29, 1978, unless otherwise noted.

42:4.0.1.1.14.1	SUBPART A	Subpart A - General Provisions
42:4.0.1.1.14.1.143.1	SECTION 456.1	456.1 Basis and purpose of part.
42:4.0.1.1.14.1.143.2	SECTION 456.2	456.2 State plan requirements.
42:4.0.1.1.14.1.143.3	SECTION 456.3	456.3 Statewide surveillance and utilization control program.
42:4.0.1.1.14.1.143.4	SECTION 456.4	456.4 Responsibility for monitoring the utilization control program.
42:4.0.1.1.14.1.143.5	SECTION 456.5	456.5 Evaluation criteria.
42:4.0.1.1.14.1.143.6	SECTION 456.6	456.6 Review by State medical agency of appropriateness and quality of services.
42:4.0.1.1.14.2	SUBPART B	Subpart B - Utilization Control: All Medicaid Services
42:4.0.1.1.14.2.143.1	SECTION 456.21	456.21 Scope.
42:4.0.1.1.14.2.143.2	SECTION 456.22	456.22 Sample basis evaluation of services.
42:4.0.1.1.14.2.143.3	SECTION 456.23	456.23 Post-payment review process.
42:4.0.1.1.14.3	SUBPART C	Subpart C - Utilization Control: Hospitals
42:4.0.1.1.14.3.143	SUBJGRP 143	Certification of Need for Care
42:4.0.1.1.14.3.143.1	SECTION 456.50	456.50 Scope.
42:4.0.1.1.14.3.143.2	SECTION 456.51	456.51 Definitions.
42:4.0.1.1.14.3.143.3	SECTION 456.60	456.60 Certification and recertification of need for inpatient care.
42:4.0.1.1.14.3.144	SUBJGRP 144	Plan of Care
42:4.0.1.1.14.3.144.4	SECTION 456.80	456.80 Individual written plan of care.
42:4.0.1.1.14.3.145	SUBJGRP 145	Utilization Review (UR) Plan: General Requirement
42:4.0.1.1.14.3.145.5	SECTION 456.100	456.100 Scope.
42:4.0.1.1.14.3.145.6	SECTION 456.101	456.101 UR plan required for inpatient hospital services.
42:4.0.1.1.14.3.146	SUBJGRP 146	UR Plan: Administrative Requirements
42:4.0.1.1.14.3.146.7	SECTION 456.105	456.105 UR committee required.
42:4.0.1.1.14.3.146.8	SECTION 456.106	456.106 Organization and composition of UR committee; disqualification from UR committee membership.
42:4.0.1.1.14.3.147	SUBJGRP 147	UR Plan: Informational Requirements
42:4.0.1.1.14.3.147.9	SECTION 456.111	456.111 Beneficiary information required for UR.
42:4.0.1.1.14.3.147.10	SECTION 456.112	456.112 Records and reports.
42:4.0.1.1.14.3.147.11	SECTION 456.113	456.113 Confidentiality.
42:4.0.1.1.14.3.148	SUBJGRP 148	UR Plan: Review of Need for Admission 1
42:4.0.1.1.14.3.148.12	SECTION 456.121	456.121 Admission review required.
42:4.0.1.1.14.3.148.13	SECTION 456.122	456.122 Evaluation criteria for admission review.
42:4.0.1.1.14.3.148.14	SECTION 456.123	456.123 Admission review process.
42:4.0.1.1.14.3.148.15	SECTION 456.124	456.124 Notification of adverse decision.
42:4.0.1.1.14.3.148.16	SECTION 456.125	456.125 Time limits for admission review.
42:4.0.1.1.14.3.148.17	SECTION 456.126	456.126 Time limits for final decision and notification of adverse decision.
42:4.0.1.1.14.3.148.18	SECTION 456.127	456.127 Pre-admission review.
42:4.0.1.1.14.3.148.19	SECTION 456.128	456.128 Initial continued stay review date.
42:4.0.1.1.14.3.148.20	SECTION 456.129	456.129 Description of methods and criteria: Initial continued stay review date; close professional scrutiny; length of stay modification.
42:4.0.1.1.14.3.149	SUBJGRP 149	UR Plan: Review of Need for Continued Stay
42:4.0.1.1.14.3.149.21	SECTION 456.131	456.131 Continued stay review required.
42:4.0.1.1.14.3.149.22	SECTION 456.132	456.132 Evaluation criteria for continued stay.
42:4.0.1.1.14.3.149.23	SECTION 456.133	456.133 Subsequent continued stay review dates.
42:4.0.1.1.14.3.149.24	SECTION 456.134	456.134 Description of methods and criteria: Subsequent continued stay review dates; length of stay modification.
42:4.0.1.1.14.3.149.25	SECTION 456.135	456.135 Continued stay review process.
42:4.0.1.1.14.3.149.26	SECTION 456.136	456.136 Notification of adverse decision.
42:4.0.1.1.14.3.149.27	SECTION 456.137	456.137 Time limits for final decision and notification of adverse decision.
42:4.0.1.1.14.3.150	SUBJGRP 150	UR Plan: Medical Care Evaluation Studies
42:4.0.1.1.14.3.150.28	SECTION 456.141	456.141 Purpose and general description.
42:4.0.1.1.14.3.150.29	SECTION 456.142	456.142 UR plan requirements for medical care evaluation studies.
42:4.0.1.1.14.3.150.30	SECTION 456.143	456.143 Content of medical care evaluation studies.
42:4.0.1.1.14.3.150.31	SECTION 456.144	456.144 Data sources for studies.
42:4.0.1.1.14.3.150.32	SECTION 456.145	456.145 Number of studies required to be performed.
42:4.0.1.1.14.4	SUBPART D	Subpart D - Utilization Control: Mental Hospitals
42:4.0.1.1.14.4.151	SUBJGRP 151	Certification of Need for Care
42:4.0.1.1.14.4.151.1	SECTION 456.150	456.150 Scope.
42:4.0.1.1.14.4.151.2	SECTION 456.151	456.151 Definitions.
42:4.0.1.1.14.4.151.3	SECTION 456.160	456.160 Certification and recertification of need for inpatient care.
42:4.0.1.1.14.4.152	SUBJGRP 152	Medical, Psychiatric, and Social Evaluations and Admission Review
42:4.0.1.1.14.4.152.4	SECTION 456.170	456.170 Medical, psychiatric, and social evaluations.
42:4.0.1.1.14.4.152.5	SECTION 456.171	456.171 [Reserved]
42:4.0.1.1.14.4.153	SUBJGRP 153	Plan of Care
42:4.0.1.1.14.4.153.6	SECTION 456.180	456.180 Individual written plan of care.
42:4.0.1.1.14.4.153.7	SECTION 456.181	456.181 Reports of evaluations and plans of care.
42:4.0.1.1.14.4.154	SUBJGRP 154	Utilization Review (UR) Plan: General Requirements
42:4.0.1.1.14.4.154.8	SECTION 456.200	456.200 Scope.
42:4.0.1.1.14.4.154.9	SECTION 456.201	456.201 UR plan required for inpatient mental hospital services.
42:4.0.1.1.14.4.155	SUBJGRP 155	UR Plan: Administrative Requirements
42:4.0.1.1.14.4.155.10	SECTION 456.205	456.205 UR committee required.
42:4.0.1.1.14.4.155.11	SECTION 456.206	456.206 Organization and composition of UR committee; disqualification from UR committee membership.
42:4.0.1.1.14.4.156	SUBJGRP 156	UR Plan: Informational Requirements
42:4.0.1.1.14.4.156.12	SECTION 456.211	456.211 Beneficiary information required for UR.
42:4.0.1.1.14.4.156.13	SECTION 456.212	456.212 Records and reports.
42:4.0.1.1.14.4.156.14	SECTION 456.213	456.213 Confidentiality.
42:4.0.1.1.14.4.157	SUBJGRP 157	UR Plan: Review of Need for Continued Stay
42:4.0.1.1.14.4.157.15	SECTION 456.231	456.231 Continued stay review required.
42:4.0.1.1.14.4.157.16	SECTION 456.232	456.232 Evaluation criteria for continued stay.
42:4.0.1.1.14.4.157.17	SECTION 456.233	456.233 Initial continued stay review date.
42:4.0.1.1.14.4.157.18	SECTION 456.234	456.234 Subsequent continued stay review dates.
42:4.0.1.1.14.4.157.19	SECTION 456.235	456.235 Description of methods and criteria: Continued stay review dates; length of stay modification.
42:4.0.1.1.14.4.157.20	SECTION 456.236	456.236 Continued stay review process.
42:4.0.1.1.14.4.157.21	SECTION 456.237	456.237 Notification of adverse decision.
42:4.0.1.1.14.4.157.22	SECTION 456.238	456.238 Time limits for final decision and notification of adverse decision.
42:4.0.1.1.14.4.158	SUBJGRP 158	UR Plan: Medical Care Evaluation Studies
42:4.0.1.1.14.4.158.23	SECTION 456.241	456.241 Purpose and general description.
42:4.0.1.1.14.4.158.24	SECTION 456.242	456.242 UR plan requirements for medical care evaluation studies.
42:4.0.1.1.14.4.158.25	SECTION 456.243	456.243 Content of medical care evaluation studies.
42:4.0.1.1.14.4.158.26	SECTION 456.244	456.244 Data sources for studies.
42:4.0.1.1.14.4.158.27	SECTION 456.245	456.245 Number of studies required to be performed.
42:4.0.1.1.14.5	SUBPART E	Subpart E [Reserved]
42:4.0.1.1.14.6	SUBPART F	Subpart F - Utilization Control: Intermediate Care Facilities
42:4.0.1.1.14.6.159	SUBJGRP 159	Certification of Need for Care
42:4.0.1.1.14.6.159.1	SECTION 456.350	456.350 Scope.
42:4.0.1.1.14.6.159.2	SECTION 456.351	456.351 Definition.
42:4.0.1.1.14.6.159.3	SECTION 456.360	456.360 Certification and recertification of need for inpatient care.
42:4.0.1.1.14.6.160	SUBJGRP 160	Medical, Psychological, and Social Evaluations and Admission Review
42:4.0.1.1.14.6.160.4	SECTION 456.370	456.370 Medical, psychological, and social evaluations.
42:4.0.1.1.14.6.160.5	SECTION 456.371	456.371 Exploration of alternative services.
42:4.0.1.1.14.6.160.6	SECTION 456.372	456.372 Medicaid agency review of need for admission.
42:4.0.1.1.14.6.161	SUBJGRP 161	Plan of Care
42:4.0.1.1.14.6.161.7	SECTION 456.380	456.380 Individual written plan of care.
42:4.0.1.1.14.6.161.8	SECTION 456.381	456.381 Reports of evaluations and plans of care.
42:4.0.1.1.14.6.162	SUBJGRP 162	Utilization Review (UR) Plan: General Requirement
42:4.0.1.1.14.6.162.9	SECTION 456.400	456.400 Scope.
42:4.0.1.1.14.6.162.10	SECTION 456.401	456.401 State plan UR requirements and options; UR plan required for intermediate care facility services.
42:4.0.1.1.14.6.163	SUBJGRP 163	UR Plan: Administrative Requirements
42:4.0.1.1.14.6.163.11	SECTION 456.405	456.405 Description of UR review function: How and when.
42:4.0.1.1.14.6.163.12	SECTION 456.406	456.406 Description of UR review function: Who performs UR; disqualification from performing UR.
42:4.0.1.1.14.6.163.13	SECTION 456.407	456.407 UR responsibilities of administrative staff.
42:4.0.1.1.14.6.164	SUBJGRP 164	UR Plan: Informational Requirements
42:4.0.1.1.14.6.164.14	SECTION 456.411	456.411 Beneficiary information required for UR.
42:4.0.1.1.14.6.164.15	SECTION 456.412	456.412 Records and reports.
42:4.0.1.1.14.6.164.16	SECTION 456.413	456.413 Confidentiality.
42:4.0.1.1.14.6.165	SUBJGRP 165	UR Plan: Review of Need for Continued Stay
42:4.0.1.1.14.6.165.17	SECTION 456.431	456.431 Continued stay review required.
42:4.0.1.1.14.6.165.18	SECTION 456.432	456.432 Evaluation criteria for continued stay.
42:4.0.1.1.14.6.165.19	SECTION 456.433	456.433 Initial continued stay review date.
42:4.0.1.1.14.6.165.20	SECTION 456.434	456.434 Subsequent continued stay review dates.
42:4.0.1.1.14.6.165.21	SECTION 456.435	456.435 Description of methods and criteria: Continued stay review dates.
42:4.0.1.1.14.6.165.22	SECTION 456.436	456.436 Continued stay review process.
42:4.0.1.1.14.6.165.23	SECTION 456.437	456.437 Notification of adverse decision.
42:4.0.1.1.14.6.165.24	SECTION 456.438	456.438 Time limits for notification of adverse decision.
42:4.0.1.1.14.7	SUBPART G	Subpart G - Inpatient Psychiatric Services for Individuals Under Age 21: Admission and Plan of Care Requirements
42:4.0.1.1.14.7.166.1	SECTION 456.480	456.480 Scope.
42:4.0.1.1.14.7.166.2	SECTION 456.481	456.481 Admission certification and plan of care.
42:4.0.1.1.14.7.166.3	SECTION 456.482	456.482 Medical, psychiatric, and social evaluations.
42:4.0.1.1.14.8	SUBPART H	Subpart H - Utilization Review Plans: FFP, Waivers, and Variances for Hospitals and Mental Hospitals
42:4.0.1.1.14.8.166	SUBJGRP 166	UR Plan: Waiver of Requirements
42:4.0.1.1.14.8.166.1	SECTION 456.500	456.500 Purpose.
42:4.0.1.1.14.8.166.2	SECTION 456.501	456.501 UR plans as a condition for FFP.
42:4.0.1.1.14.8.166.3	SECTION 456.505	456.505 Applicability of waiver.
42:4.0.1.1.14.8.166.4	SECTION 456.506	456.506 Waiver options for Medicaid agency.
42:4.0.1.1.14.8.166.5	SECTION 456.507	456.507 Review and granting of waiver requests.
42:4.0.1.1.14.8.166.6	SECTION 456.508	456.508 Withdrawal of waiver.
42:4.0.1.1.14.8.167	SUBJGRP 167	UR Plan: Remote Facility Variances from Time Requirements
42:4.0.1.1.14.8.167.7	SECTION 456.520	456.520 Definitions.
42:4.0.1.1.14.8.167.8	SECTION 456.521	456.521 Conditions for granting variance requests.
42:4.0.1.1.14.8.167.9	SECTION 456.522	456.522 Content of request for variance.
42:4.0.1.1.14.8.167.10	SECTION 456.523	456.523 Revised UR plan.
42:4.0.1.1.14.8.167.11	SECTION 456.524	456.524 Notification of Administrator's action and duration of variance.
42:4.0.1.1.14.8.167.12	SECTION 456.525	456.525 Request for renewal of variance.
42:4.0.1.1.14.9	SUBPART I	Subpart I - Inspections of Care in Intermediate Care Facilities and Institutions for Mental Diseases
42:4.0.1.1.14.9.168.1	SECTION 456.600	456.600 Purpose.
42:4.0.1.1.14.9.168.2	SECTION 456.601	456.601 Definitions.
42:4.0.1.1.14.9.168.3	SECTION 456.602	456.602 Inspection team.
42:4.0.1.1.14.9.168.4	SECTION 456.603	456.603 Financial interests and employment of team members.
42:4.0.1.1.14.9.168.5	SECTION 456.604	456.604 Physician team member inspecting care of beneficiaries.
42:4.0.1.1.14.9.168.6	SECTION 456.605	456.605 Number and location of teams.
42:4.0.1.1.14.9.168.7	SECTION 456.606	456.606 Frequency of inspections.
42:4.0.1.1.14.9.168.8	SECTION 456.607	456.607 Notification before inspection.
42:4.0.1.1.14.9.168.9	SECTION 456.608	456.608 Personal contact with and observation of beneficiaries and review of records.
42:4.0.1.1.14.9.168.10	SECTION 456.609	456.609 Determinations by team.
42:4.0.1.1.14.9.168.11	SECTION 456.610	456.610 Basis for determinations.
42:4.0.1.1.14.9.168.12	SECTION 456.611	456.611 Reports on inspections.
42:4.0.1.1.14.9.168.13	SECTION 456.612	456.612 Copies of reports.
42:4.0.1.1.14.9.168.14	SECTION 456.613	456.613 Action on reports.
42:4.0.1.1.14.9.168.15	SECTION 456.614	456.614 Inspections by utilization review committee.
42:4.0.1.1.14.10	SUBPART J	Subpart J - Penalty for Failure To Make a Satisfactory Showing of an Effective Institutional Utilization Control Program
42:4.0.1.1.14.10.168.1	SECTION 456.650	456.650 Basis, purpose and scope.
42:4.0.1.1.14.10.168.2	SECTION 456.651	456.651 Definitions.
42:4.0.1.1.14.10.168.3	SECTION 456.652	456.652 Requirements for an effective utilization control program.
42:4.0.1.1.14.10.168.4	SECTION 456.653	456.653 Acceptable reasons for not meeting requirements for annual on-site review.
42:4.0.1.1.14.10.168.5	SECTION 456.654	456.654 Requirements for content of showings and procedures for submittal.
42:4.0.1.1.14.10.168.6	SECTION 456.655	456.655 Validation of showings.
42:4.0.1.1.14.10.168.7	SECTION 456.656	456.656 Reductions in FFP.
42:4.0.1.1.14.10.168.8	SECTION 456.657	456.657 Computation of reductions in FFP.
42:4.0.1.1.14.11	SUBPART K	Subpart K - Drug Use Review (DUR) Program and Electronic Claims Management System for Outpatient Drug Claims
42:4.0.1.1.14.11.168.1	SECTION 456.700	456.700 Scope.
42:4.0.1.1.14.11.168.2	SECTION 456.702	456.702 Definitions.
42:4.0.1.1.14.11.168.3	SECTION 456.703	456.703 Drug use review program.
42:4.0.1.1.14.11.168.4	SECTION 456.705	456.705 Prospective drug review.
42:4.0.1.1.14.11.168.5	SECTION 456.709	456.709 Retrospective drug use review.
42:4.0.1.1.14.11.168.6	SECTION 456.711	456.711 Educational program.
42:4.0.1.1.14.11.168.7	SECTION 456.712	456.712 Annual report.
42:4.0.1.1.14.11.168.8	SECTION 456.714	456.714 DUR/surveillance and utilization review relationship.
42:4.0.1.1.14.11.168.9	SECTION 456.716	456.716 DUR Board.
42:4.0.1.1.14.11.168.10	SECTION 456.719	456.719 Funding for DUR program.
42:4.0.1.1.14.11.168.11	SECTION 456.722	456.722 Electronic claims management system.
42:4.0.1.1.14.11.168.12	SECTION 456.725	456.725 Funding of ECM system.

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