CERTIFICATION OF NEED FOR CARE

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

• § 456.50 - Scope.

• § 456.51 - Definitions.

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 - Beneficiary information required for UR.

• § 456.112 - Records and reports.

• § 456.113 - Confidentiality.

UR PLAN: REVIEW OF NEED FOR ADMISSION 1

• § 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.

• § 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.