Subpart C. Subpart C—Utilization Control: Hospitals

• § 456.50 - Scope.
• § 456.51 - Definitions.

• Certification of Need for Care

  • SECTION § 456.60 - Certification and recertification of need for inpatient care.

• Plan of Care

  • SECTION § 456.80 - Individual written plan of care.

• Utilization Review (UR) Plan: General Requirement

  • SECTION § 456.100 - Scope.
  • SECTION § 456.101 - UR plan required for inpatient hospital services.

• UR Plan: Administrative Requirements

  • SECTION § 456.105 - UR committee required.
  • SECTION § 456.106 - Organization and composition of UR committee; disqualification from UR committee membership.

• UR Plan: Informational Requirements

  • SECTION § 456.111 - Beneficiary information required for UR.
  • SECTION § 456.112 - Records and reports.
  • SECTION § 456.113 - Confidentiality.

• UR Plan: Review of Need for Admission 1

  • SECTION § 456.121 - Admission review required.
  • SECTION § 456.122 - Evaluation criteria for admission review.
  • SECTION § 456.123 - Admission review process.
  • SECTION § 456.124 - Notification of adverse decision.
  • SECTION § 456.125 - Time limits for admission review.
  • SECTION § 456.126 - Time limits for final decision and notification of adverse decision.
  • SECTION § 456.127 - Pre-admission review.
  • SECTION § 456.128 - Initial continued stay review date.
  • SECTION § 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

  • SECTION § 456.131 - Continued stay review required.
  • SECTION § 456.132 - Evaluation criteria for continued stay.
  • SECTION § 456.133 - Subsequent continued stay review dates.
  • SECTION § 456.134 - Description of methods and criteria: Subsequent continued stay review dates; length of stay modification.
  • SECTION § 456.135 - Continued stay review process.
  • SECTION § 456.136 - Notification of adverse decision.
  • SECTION § 456.137 - Time limits for final decision and notification of adverse decision.

• UR Plan: Medical Care Evaluation Studies

  • SECTION § 456.141 - Purpose and general description.
  • SECTION § 456.142 - UR plan requirements for medical care evaluation studies.
  • SECTION § 456.143 - Content of medical care evaluation studies.
  • SECTION § 456.144 - Data sources for studies.
  • SECTION § 456.145 - Number of studies required to be performed.