Title 42

SECTION 456.436

456.436 Continued stay review process.

§ 456.436 Continued stay review process.

The UR plan must provide that -

(a) Review of continued stay cases is conducted by -

(1) The group performing UR; or

(2) A designee of the UR group;

(b) The group or its designee reviews a beneficiary's continued stay on or before the expiration of each assigned continued stay review date.

(c) For each continued stay of a beneficiary in the ICF, the group or its designee reviews and evaluates the documentation described under § 456.411 against the criteria developed under § 456.432 and applies close professional scrutiny to cases described under § 456.432(b);

(d) If the group or its designee finds that a beneficiary's continued stay in the ICF is needed, the group assigns a new continued stay review date in accordance with § 456.434;

(e) If the group or its designee finds that a continued stay case does not meet the criteria, the group or a subgroup that includes at least one physician reviews the case to decide the need for continued stay;

(f) If the group or subgroup making the review under paragraph (e) of this section finds that a continued stay is not needed, it notifies the beneficiary's attending physician or, in institutions for individuals with intellectual disabilities, the beneficiary's qualified Intellectual Disability professional, within 1 working day of its decision, and gives him 2 working days from the notification date to present his views before it makes a final decision on the need for the continued stay;

(g) If the attending physician or qualified Intellectual Disability professional does not present additional information or clarification of the need for the continued stay, the decision of the UR group is final;

(h) If the attending physician or qualified Intellectual Disability professional presents additional information or clarification, the need for continued stay is reviewed by -

(1) The physician member(s) of the UR group, in cases involving a medical determination; or

(2) The UR group, in cases not involving a medical determination; and

(i) If the individuals performing the review under paragraph (h) of this section find that the beneficiary no longer needs ICF services, their decision is final.

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