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FEDERAL · 42 CFR

Part 456 — Utilization Control

142 sections · Title 42: Public Health

§ 456.1Basis and purpose of part.
§ 456.2State plan requirements.
§ 456.3Statewide surveillance and utilization control program.
§ 456.4Responsibility for monitoring the utilization control program.
§ 456.5Evaluation criteria.
§ 456.6Review by State medical agency of appropriateness and quality of services.
§ 456.21Scope.
§ 456.22Sample basis evaluation of services.
§ 456.23Post-payment review process.
§ 456.50Scope.
§ 456.51Definitions.
§ 456.60Certification and recertification of need for inpatient care.
§ 456.80Individual written plan of care.
§ 456.100Scope.
§ 456.101UR plan required for inpatient hospital services.
§ 456.105UR committee required.
§ 456.106Organization and composition of UR committee; disqualification from UR committee membership.
§ 456.111Beneficiary information required for UR.
§ 456.112Records and reports.
§ 456.113Confidentiality.
§ 456.121Admission review required.
§ 456.122Evaluation criteria for admission review.
§ 456.123Admission review process.
§ 456.124Notification of adverse decision.
§ 456.125Time limits for admission review.
§ 456.126Time limits for final decision and notification of adverse decision.
§ 456.127Pre-admission review.
§ 456.128Initial continued stay review date.
§ 456.129Description of methods and criteria: Initial continued stay review date; close professional scrutiny; length of stay modification.
§ 456.131Continued stay review required.
§ 456.132Evaluation criteria for continued stay.
§ 456.133Subsequent continued stay review dates.
§ 456.134Description of methods and criteria: Subsequent continued stay review dates; length of stay modification.
§ 456.135Continued stay review process.
§ 456.136Notification of adverse decision.
§ 456.137Time limits for final decision and notification of adverse decision.
§ 456.141Purpose and general description.
§ 456.142UR plan requirements for medical care evaluation studies.
§ 456.143Content of medical care evaluation studies.
§ 456.144Data sources for studies.
§ 456.145Number of studies required to be performed.
§ 456.150Scope.
§ 456.151Definitions.
§ 456.160Certification and recertification of need for inpatient care.
§ 456.170Medical, psychiatric, and social evaluations.
§ 456.171§ 456.171 [Reserved]
§ 456.180Individual written plan of care.
§ 456.181Reports of evaluations and plans of care.
§ 456.200Scope.
§ 456.201UR plan required for inpatient mental hospital services.
§ 456.205UR committee required.
§ 456.206Organization and composition of UR committee; disqualification from UR committee membership.
§ 456.211Beneficiary information required for UR.
§ 456.212Records and reports.
§ 456.213Confidentiality.
§ 456.231Continued stay review required.
§ 456.232Evaluation criteria for continued stay.
§ 456.233Initial continued stay review date.
§ 456.234Subsequent continued stay review dates.
§ 456.235Description of methods and criteria: Continued stay review dates; length of stay modification.
§ 456.236Continued stay review process.
§ 456.237Notification of adverse decision.
§ 456.238Time limits for final decision and notification of adverse decision.
§ 456.241Purpose and general description.
§ 456.242UR plan requirements for medical care evaluation studies.
§ 456.243Content of medical care evaluation studies.
§ 456.244Data sources for studies.
§ 456.245Number of studies required to be performed.
§ 456.350Scope.
§ 456.351Definition.
§ 456.360Certification and recertification of need for inpatient care.
§ 456.370Medical, psychological, and social evaluations.
§ 456.371Exploration of alternative services.
§ 456.372Medicaid agency review of need for admission.
§ 456.380Individual written plan of care.
§ 456.381Reports of evaluations and plans of care.
§ 456.400Scope.
§ 456.401State plan UR requirements and options; UR plan required for intermediate care facility services.
§ 456.405Description of UR review function: How and when.
§ 456.406Description of UR review function: Who performs UR; disqualification from performing UR.
§ 456.407UR responsibilities of administrative staff.
§ 456.411Beneficiary information required for UR.
§ 456.412Records and reports.
§ 456.413Confidentiality.
§ 456.431Continued stay review required.
§ 456.432Evaluation criteria for continued stay.
§ 456.433Initial continued stay review date.
§ 456.434Subsequent continued stay review dates.
§ 456.435Description of methods and criteria: Continued stay review dates.
§ 456.436Continued stay review process.
§ 456.437Notification of adverse decision.
§ 456.438Time limits for notification of adverse decision.
§ 456.480Scope.
§ 456.481Admission certification and plan of care.
§ 456.482Medical, psychiatric, and social evaluations.
§ 456.500Purpose.
§ 456.501UR plans as a condition for FFP.
§ 456.505Applicability of waiver.
§ 456.506Waiver options for Medicaid agency.
§ 456.507Review and granting of waiver requests.
§ 456.508Withdrawal of waiver.
§ 456.520Definitions.
§ 456.521Conditions for granting variance requests.
§ 456.522Content of request for variance.
§ 456.523Revised UR plan.
§ 456.524Notification of Administrator's action and duration of variance.
§ 456.525Request for renewal of variance.
§ 456.600Purpose.
§ 456.601Definitions.
§ 456.602Inspection team.
§ 456.603Financial interests and employment of team members.
§ 456.604Physician team member inspecting care of beneficiaries.
§ 456.605Number and location of teams.
§ 456.606Frequency of inspections.
§ 456.607Notification before inspection.
§ 456.608Personal contact with and observation of beneficiaries and review of records.
§ 456.609Determinations by team.
§ 456.610Basis for determinations.
§ 456.611Reports on inspections.
§ 456.612Copies of reports.
§ 456.613Action on reports.
§ 456.614Inspections by utilization review committee.
§ 456.650Basis, purpose and scope.
§ 456.651Definitions.
§ 456.652Requirements for an effective utilization control program.
§ 456.653Acceptable reasons for not meeting requirements for annual on-site review.
§ 456.654Requirements for content of showings and procedures for submittal.
§ 456.655Validation of showings.
§ 456.656Reductions in FFP.
§ 456.657Computation of reductions in FFP.
§ 456.700Scope.
§ 456.702Definitions.
§ 456.703Drug use review program.
§ 456.705Prospective drug review.
§ 456.709Retrospective drug use review.
§ 456.711Educational program.
§ 456.712Annual report.
§ 456.714DUR/surveillance and utilization review relationship.
§ 456.716DUR Board.
§ 456.719Funding for DUR program.
§ 456.722Electronic claims management system.
§ 456.725Funding of ECM system.