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
Subpart C — Utilization Control: Hospitals
- § 456.50— Scope.
- § 456.51— Definitions.
- § 456.60— Certification and recertification of need for inpatient care.
- § 456.80— Individual written plan of care.
- § 456.100— Scope.
- § 456.101— UR plan required for inpatient hospital services.
- § 456.105— UR committee required.
- § 456.106— Organization and composition of UR committee; disqualification from UR committee membership.
- § 456.111— Beneficiary information required for UR.
- § 456.112— Records and reports.
- § 456.113— Confidentiality.
- § 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.
- § 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.
- § 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.
Subpart D — Utilization Control: Mental Hospitals
- § 456.150— Scope.
- § 456.151— Definitions.
- § 456.160— Certification and recertification of need for inpatient care.
- § 456.170— Medical, psychiatric, and social evaluations.
- § 456.180— Individual written plan of care.
- § 456.181— Reports of evaluations and plans of care.
- § 456.200— Scope.
- § 456.201— UR plan required for inpatient mental hospital services.
- § 456.205— UR committee required.
- § 456.206— Organization and composition of UR committee; disqualification from UR committee membership.
- § 456.211— Beneficiary information required for UR.
- § 456.212— Records and reports.
- § 456.213— Confidentiality.
- § 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.
- § 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.
Subpart F — Utilization Control: Intermediate Care Facilities
- § 456.350— Scope.
- § 456.351— Definition.
- § 456.360— Certification and recertification of need for inpatient care.
- § 456.370— Medical, psychological, and social evaluations.
- § 456.371— Exploration of alternative services.
- § 456.372— Medicaid agency review of need for admission.
- § 456.380— Individual written plan of care.
- § 456.381— Reports of evaluations and plans of care.
- § 456.400— Scope.
- § 456.401— State plan UR requirements and options; UR plan required for intermediate care facility services.
- § 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.
- § 456.411— Beneficiary information required for UR.
- § 456.412— Records and reports.
- § 456.413— Confidentiality.
- § 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.
Subpart G — Inpatient Psychiatric Services for Individuals Under Age 21: Admission and Plan of Care Requirements
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.
- § 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.
- § 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.