CFR /  Title 42  /  Part 456: Utilization Control

Section No.	Description
Section 456.1	State plan requirements
Section 456.2	Statewide surveillance and utilization control program
Section 456.3	Responsibility for monitoring the utilization control program
Section 456.4	Evaluation criteria
Section 456.5	Review by State medical agency of appropriateness and quality of services
Section 456.6	Scope
Section 456.21	Sample basis evaluation of services
Section 456.22	Post-payment review process
Section 456.23	Scope
Section 456.50	Definitions
Section 456.51	Certification and recertification of need for inpatient care
Section 456.60	Individual written plan of care
Section 456.80	Scope
Section 456.100	UR plan required for inpatient hospital services
Section 456.101	UR committee required
Section 456.105	Organization and composition of UR committee; disqualification from UR committee membership
Section 456.106	Beneficiary information required for UR
Section 456.111	Records and reports
Section 456.112	Confidentiality
Section 456.113	Admission review required
Section 456.121	Evaluation criteria for admission review
Section 456.122	Admission review process
Section 456.123	Notification of adverse decision
Section 456.124	Time limits for admission review
Section 456.125	Time limits for final decision and notification of adverse decision
Section 456.126	Pre-admission review
Section 456.127	Initial continued stay review date
Section 456.128	Description of methods and criteria: Initial continued stay review date; close professional scrutiny; length of stay
Section 456.129	Continued stay review required
Section 456.131	Evaluation criteria for continued stay
Section 456.132	Subsequent continued stay review dates
Section 456.133	Description of methods and criteria: Subsequent continued stay review dates; length of stay modification
Section 456.134	Continued stay review process
Section 456.135	Notification of adverse decision
Section 456.136	Time limits for final decision and notification of adverse decision
Section 456.137	Purpose and general description
Section 456.141	UR plan requirements for medical care evaluation studies
Section 456.142	Content of medical care evaluation studies
Section 456.143	Data sources for studies
Section 456.144	Number of studies required to be performed
Section 456.145	Scope
Section 456.150	Definitions
Section 456.151	Certification and recertification of need for inpatient care
Section 456.160	Medical, psychiatric, and social evaluations
Section 456.170	Medicaid agency review of need for admission
Section 456.171	Individual written plan of care
Section 456.180	Reports of evaluations and plans of care
Section 456.181	Scope
Section 456.200	UR plan required for inpatient mental hospital services
Section 456.201	UR committee required
Section 456.205	Organization and composition of UR committee; disqualification from UR committee membership
Section 456.206	Beneficiary information required for UR
Section 456.211	Records and reports
Section 456.212	Confidentiality
Section 456.213	Continued stay review required
Section 456.231	Evaluation criteria for continued stay
Section 456.232	Initial continued stay review date
Section 456.233	Subsequent continued stay review dates
Section 456.234	Description of methods and criteria: Continued stay review dates; length of stay modification
Section 456.235	Continued stay review process
Section 456.236	Notification of adverse decision
Section 456.237	Time limits for final decision and notification of adverse decision
Section 456.238	Purpose and general description
Section 456.241	UR plan requirements for medical care evaluation studies
Section 456.242	Content of medical care evaluation studies
Section 456.243	Data sources for studies
Section 456.244	Number of studies required to be performed
Section 456.245	Scope
Section 456.350	Definition
Section 456.351	Certification and recertification of need for inpatient care
Section 456.360	Medical, psychological, and social evaluations
Section 456.370	Exploration of alternative services
Section 456.371	Medicaid agency review of need for admission
Section 456.372	Individual written plan of care
Section 456.380	Reports of evaluations and plans of care
Section 456.381	Scope
Section 456.400	State plan UR requirements and options; UR plan required for intermediate care facility services
Section 456.401	Description of UR review function: How and when
Section 456.405	Description of UR review function: Who performs UR; disqualification from performing UR
Section 456.406	UR responsibilities of administrative staff
Section 456.407	Beneficiary information required for UR
Section 456.411	Records and reports
Section 456.412	Confidentiality
Section 456.413	Continued stay review required
Section 456.431	Evaluation criteria for continued stay
Section 456.432	Initial continued stay review date
Section 456.433	Subsequent continued stay review dates
Section 456.434	Description of methods and criteria: Continued stay review dates
Section 456.435	Continued stay review process
Section 456.436	Notification of adverse decision
Section 456.437	Time limits for notification of adverse decision
Section 456.438	Scope
Section 456.480	Admission certification and plan of care
Section 456.481	Medical, psychiatric, and social evaluations
Section 456.482	Purpose
Section 456.500	UR plans as a condition for FFP
Section 456.501	Applicability of waiver
Section 456.505	Waiver options for Medicaid agency
Section 456.506	Review and granting of waiver requests
Section 456.507	Withdrawal of waiver
Section 456.508	Definitions
Section 456.520	Conditions for granting variance requests
Section 456.521	Content of request for variance
Section 456.522	Revised UR plan
Section 456.523	Notification of Administrator's action and duration of variance
Section 456.524	Request for renewal of variance
Section 456.525	Purpose
Section 456.600	Definitions
Section 456.601	Inspection team
Section 456.602	Financial interests and employment of team members
Section 456.603	Physician team member inspecting care of beneficiaries
Section 456.604	Number and location of teams
Section 456.605	Frequency of inspections
Section 456.606	Notification before inspection
Section 456.607	Personal contact with and observation of beneficiaries and review of records
Section 456.608	Determinations by team
Section 456.609	Basis for determinations
Section 456.610	Reports on inspections
Section 456.611	Copies of reports
Section 456.612	Action on reports
Section 456.613	Inspections by utilization review committee
Section 456.614	Basis, purpose and scope
Section 456.650	Definitions
Section 456.651	Requirements for an effective utilization control program
Section 456.652	Acceptable reasons for not meeting requirements for annual on-site review
Section 456.653	Requirements for content of showings and procedures for submittal
Section 456.654	Validation of showings
Section 456.655	Reductions in FFP
Section 456.656	Computation of reductions in FFP
Section 456.657	Scope
Section 456.700	Definitions
Section 456.702	Drug use review program
Section 456.703	Prospective drug review
Section 456.705	Retrospective drug use review
Section 456.709	Educational program
Section 456.711	Annual report
Section 456.712	DUR/surveillance and utilization review relationship
Section 456.714	DUR Board
Section 456.716	Funding for DUR program
Section 456.719	Electronic claims management system
Section 456.722	Funding of ECM system
Section 456.725	Program description