2004 CFR Title 42, Volume 3

Title 42--Public Health CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PART 456--UTILIZATION CONTROL
	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.
	456.21	Scope.
	456.22	Sample basis evaluation of services.
	456.23	Post-payment review process.
	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	Recipient 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.
	456.150	Scope.
	456.151	Definitions.
	456.160	Certification and recertification of need for inpatient care.
	456.170	Medical, psychiatric, and social evaluations.
	456.171	Medicaid agency review of need for admission.
	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	Recipient 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.
	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	Recipient 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.
	456.480	Scope.
	456.481	Admission certification and plan of care.
	456.482	Medical, psychiatric, and social evaluations.
	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.
	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 recipients.
	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 recipients 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.
	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.
	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.