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(v) The investigation or prosecution of cases of suspected recipient fraud not involving suspected conspiracy with a provider; or

(vi) Any payment, direct or indirect, from the unit to the Medicaid agency, other than payments for the salaries of employees on detail to the unit.

(k) Other applicable HHS regulations. Except as otherwise provided in this subpart, the following regulations from 45 CFR Subtitle A apply to grants under this subpart: Subpart C of Part 16-Department Grant Appeals Process-Special Provisions Applicable To Reconsideration of Disallowances (note that this applies only to disallowance determinations and not to any other determinations, e.g., over certification or recertification)

Part 74-Administration of Grants Part 75-Informal Grant Appeals Procedures

Part 80-Nondiscrimination

grams

Under ProReceiving Federal Assistance Through the Department of Health and Human Services: Effectuation of Title VI of the Civil Rights Act of 1964 Part 81-Practice and Procedure for Hearings Under 45 CFR Part 80

Part 84-Nondiscrimination on the Basis of Handicap in Programs and Activities Receiving or Benefiting From Federal Financial Assistance

[43 FR 45262, Sept. 29, 1978, as amended at 45 FR 13076, Feb. 28, 1980; 45 FR 51559, Aug. 4, 1980]

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Subpart C-Utilization Control: Hospitals

Sec.
456.50 Scope.
456.51

Definitions.

CERTIFICATION OF NEED FOR CARE 456.60 Physician certification and recertification of need for inpatient care.

PLAN OF CARE

456.80 Individual written plan of care. UTILIZATION REVIEW (UR) PLAN: GENERAL REQUIREMENT

456.100 Scope.

456.101 UR plan required for inpatient hospital services.

UR PLAN: ADMINISTRATIVE REQUIREMENTS 456.105 UR committee required. 456.106 Organization and composition of UR committee; disqualification from UR committee membership.

UR PLAN: INFORMATIONAL REQUIREMENTS 456.111 Recipient information required for UR.

456.112 Records and reports. 456.113 Confidentiality.

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: 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: MEDICAL CARE EVALUATION
STUDIES

456.141 Purpose and general description.

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UTILIZATION REVIEW (UR) PLAN: GENERAL REQUIREMENT

456.200 Scope. 456.201 UR plan required for inpatient mental hospital services.

UR PLAN: ADMINISTRATIVE REQUIREMENTS 456.205 UR committee required. 456.206 Organization and composition of UR committee; disqualification from UR committee membership.

UR PLAN: INFORMATIONAL REQUIREMENTS 456.211 Recipient information required for UR.

456.212 Records and reports. 456.213 Confidentiality.

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.

456.250 Scope.

456.251

Definitions.

CERTIFICATION OF NEED FOR CARE

456.260 Physician certification and recertification of need for inpatient care.

MEDICAL, PSYCHIATRIC, AND SOCIAL
EVALUATIONS, AND ADMISSION REVIEW

456.270 Medical, psychiatric, and social evaluations.

456.271 Medicaid agency review of need for

admission.

PLAN OF CARE

456.280 Individual written plan of care. 456.281 Reports of evaluations and plans of care.

UTILIZATION REVIEW (UR) PLAN: GENERAL REQUIREMENT

456.300 Scope.

456.301 UR plan required for skilled nursing facility services.

UR PLAN: ADMINISTRATIVE REQUIREMENTS 456.305 UR committee required. 456.306 Organization and composition of UR committee; disqualification from UR committee membership.

UR PLAN: INFORMATIONAL REQUIREMENTS 456.311 Recipient information required for UR.

456.312 Records and reports. 456.313 Confidentiality.

UR PLAN: REVIEW OF NEED FOR CONTINUED STAY

456.331 Continued stay review required. 456.332 Evaluation criteria for continued stay.

456.333 Initial continued stay review date. 456.334 Subsequent continued stay review dates.

456.335 Description of methods and criteria: Continued stay review dates; length of stay modification.

456.336 Continued stay review process.

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§ 456.1 Basis and purpose of part.

(a) This part prescribes requirements concerning control of the utilization of Medicaid services including—

(1) A statewide program of control of the utilization of all Medicaid services; and

(2) Specific requirements for the control of the utilization of Medicaid services in institutions.

(b) The requirements in this part are based on the following sections of the Act. Table 1 shows the relationship between these sections of the Act and the requirements in this part.

(1) Methods and procedures to safeguard against unnecessary utilization of care and services. Section 1902(a)(30) requires that the State plan provide methods and procedures to safeguard against unnecessary utilization of care and services.

(2) Penalty for failure to have an effective program to control utilization of institutional services. Section 1903(g)(1) provides for a reduction in

the amount of Federal Medicaid funds paid to a State for long-stay inpatient services if the State does not make a showing satisfactory to the Secretary that it has an effective program of control over utilization of those services. This penalty provision applies to inpatient services in hospitals, mental hospitals, skilled nursing facilities (SNF's), and intermediate care facilities (ICF's). Specific requirements are:

(i) Under section 1903(g)(1)(A), a physician must certify at admission, and periodically recertify, the individual's need for inpatient care.

(ii) Under section 1903(g)(1)(B), services must be furnished under a plan established and periodically evaluated by a physician.

(iii) Under section 1903(g)(1)(C), the State must have in effect a continuous program of review of utilization of care and services under section 1902(a)(30) whereby each admission is reviewed or screened in accordance with criteria established by medical and other professional personnel.

(iv) Under section 1903(g)(1)(D), the State must have an effective program under sections 1902(a) (26) and (31) of review of care in skilled nursing and intermediate care facilities and mental hospitals. This must include evaluation at least annually of the professional management of each case.

(3) Medical review in skilled nursing facilities and mental hospitals. Section 1902(a)(26)(A) requires that the plan provide for a program of medical review that includes a medical evaluation of each individual's need for care in a SNF or mental hospital, a plan of care, and, where applicable, a plan of rehabilitation.

(4) Independent professional review in intermediate care facilities. Section 1902(a)(31)(A) requires that the plan provide for a program of independent professional review that includes a medical evaluation of each individual's need for intermediate care and a written plan of service.

(5) Inspection of care and services in institutions. Sections 1902(a)(26) (B) and (C) and 1902(a)(31) (B) and (C) require that the plan provide for periodic inspections and reports, by a team of professional persons, of the care being provided to each recipient in

SNF's, institutions for mental diseases (IMD's), and ICF's participating in Medicaid.

(6) Denial of FFP for failure to have specified utilization review procedures. Section 1903(i)(4) provides that FFP is not available in a State's expenditures for hospital, mental hospital, or SNF services unless the institution has in effect a utilization review plan that meets Medicare requirements. However, the Secretary may waive this requirement if the Medicaid agency demonstrates to his satisfaction that it has utilization review procedures superior in effectiveness to the Medicare procedures.

(7) State health agency guidance on quality and appropriateness of care and services. Section 1902(a)(33)(A) requires that the plan provide that the State health or other appropriate medical agency establish a plan for review, by professional health personnel, of the appropriateness and quality of Medicaid services to provide guidance to the Medicaid agency and the State licensing agency in administering the Medicaid program.

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§ 456.2 State plan requirements.

A State plan must provide that the requirements of this part are met.

§ 456.3 Statewide surveillance and utilization control program.

The Medicaid agency must implement a statewide surveillance and utilization control program that—

(a) Safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments;

(b) Assesses the quality of those services;

(c) Provides for the control of the utilization of all services provided under the plan in accordance with Subpart B of this part; and

(d) Provides for the control of the utilization of inpatient services in accordance with Subparts C through I of this part.

§ 456.4 Responsibility for monitoring the utilization control program.

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(a) The agency must

(1) Monitor the statewide utilization control program;

(2) Take all necessary corrective action to ensure the effectiveness of

the program;

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