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Code of Federal Regulations (Last Updated: November 8, 2024) |
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Title 42 - Public Health |
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Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services |
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SubChapter C - Medical Assistance Programs |
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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. |
| Ur Plan: Administrative Requirements |
| § 456.105 - UR committee required. |
| § 456.106 - Organization and composition of UR committee; disqualification from UR committee membership. |
| Ur Plan: Medical Care Evaluation Studies |
| § 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. |
| UR Plan: Review of Need for Admission 1 |
| Plan of Care |
| § 456.80 - Individual written plan of care. |
| Ur Plan: Review of Need for Continued Stay |
| § 456.131 - Continued 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 - Continued stay review process. |
| § 456.136 - Notification of adverse decision. |
| § 456.137 - Time limits for final decision and notification of adverse decision. |
| Ur Plan: Review of Need for Admission 1 |
| Utilization Review (Ur) Plan: General Requirement |
| § 456.100 - Scope. |
| § 456.101 - UR plan required for inpatient hospital services. |
| Certification of Need for Care |
| § 456.60 - Certification and recertification of need for inpatient care. |
| UR Plan: Review of Need for Admission |
| § 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. |
| Ur Plan: Informational Requirements |
| § 456.111 - Beneficiary information required for UR. |
| § 456.112 - Records and reports. |
| § 456.113 - Confidentiality. |
| Subpart D - Utilization Control: Mental Hospitals |
| § 456.150 - Scope. |
| § 456.151 - Definitions. |
| Medical, Psychiatric, and Social Evaluations and Admission Review |
| § 456.170 - Medical, psychiatric, and social evaluations. |
| § 456.171 - [Reserved] |
| Plan of Care |
| § 456.180 - Individual written plan of care. |
| § 456.181 - Reports of evaluations and plans of care. |
| Ur Plan: Medical Care Evaluation Studies |
| § 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. |
| Utilization Review (Ur) Plan: General Requirements |
| § 456.200 - Scope. |
| § 456.201 - UR plan required for inpatient mental hospital services. |
| Ur Plan: Informational Requirements |
| § 456.211 - Beneficiary information required for UR. |
| § 456.212 - Records and reports. |
| § 456.213 - Confidentiality. |
| Certification of Need for Care |
| § 456.160 - Certification and recertification of need for inpatient care. |
| Ur Plan: Review of Need for Continued Stay |
| § 456.231 - Continued 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 - Continued stay review process. |
| § 456.237 - Notification of adverse decision. |
| § 456.238 - Time limits for final decision and notification of adverse decision. |
| Ur Plan: Administrative Requirements |
| § 456.205 - UR committee required. |
| § 456.206 - Organization and composition of UR committee; disqualification from UR committee membership. |
| Subpart E - XXX |
| Subpart F - Utilization Control: Intermediate Care Facilities |
| § 456.350 - Scope. |
| § 456.351 - Definition. |
| Utilization Review (Ur) Plan: General Requirement |
| § 456.400 - Scope. |
| § 456.401 - State plan UR requirements and options; UR plan required for intermediate care facility services. |
| Medical, Psychological, and Social Evaluations and Admission Review |
| § 456.370 - Medical, psychological, and social evaluations. |
| § 456.371 - Exploration of alternative services. |
| § 456.372 - Medicaid agency review of need for admission. |
| Certification of Need for Care |
| § 456.360 - Certification and recertification of need for inpatient care. |
| Ur Plan: Review of Need for Continued Stay |
| § 456.431 - Continued 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 - Continued stay review process. |
| § 456.437 - Notification of adverse decision. |
| § 456.438 - Time limits for notification of adverse decision. |
| Ur Plan: Informational Requirements |
| § 456.411 - Beneficiary information required for UR. |
| § 456.412 - Records and reports. |
| § 456.413 - Confidentiality. |
| Ur Plan: Administrative Requirements |
| § 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. |
| Plan of Care |
| § 456.380 - Individual written plan of care. |
| § 456.381 - Reports of evaluations and plans of care. |
| 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. |
| Ur Plan: Waiver of Requirements |
| § 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. |
| Ur Plan: Remote Facility Variances from Time Requirements |
| § 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 beneficiaries. |
| § 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 beneficiaries 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. |