---
kind: "range"
citation: "42 C.F.R. §§ 456.121–456.129"
title: "42"
from: "456.121"
to: "456.129"
count: 9
url: "https://uscodex.org/cfr/42/456.121..456.129"
---

# §456.121. Admission review required.


The UR plan must provide for a review of each beneficiary's admission to the hospital to decide whether it is needed, in accordance with the requirements of [§§ 456.122 through 456.129](/cfr/42/456.122..456.129.md).


# §456.122. Evaluation criteria for admission review.


The UR plan must provide that—

- (a) The committee develops written medical care criteria to assess the need for admission; and
- (b) **The committee develops more extensive written criteria for cases that its experience shows are—**
  - (1) Associated with high costs;
  - (2) Associated with the frequent furnishing of excessive services; or
  - (3) **Attended by physicians whose patterns of care are frequently found to be questionable.**

# §456.123. Admission review process.


The UR plan must provide that—

- (a) **Admission review is conducted by—**
  - (1) The UR committee;
  - (2) A subgroup of the UR committee; or
  - (3) A designee of the UR committee;
- (b) The committee, subgroup, or designee evaluates the admission against the criteria developed under [§ 456.122](/cfr/42/456.122.md) and applies close professional scrutiny to cases selected under [§ 456.129(b)](/cfr/42/456.129.md?p=b);
- (c) If the committee, subgroup, or designee finds that the admission is needed, the committee assigns an initial continued stay review date in accordance with [§ 456.128](/cfr/42/456.128.md);
- (d) If the committee, subgroup, or designee finds that the admission does not meet the criteria, the committee or a subgroup that includes at least one physician reviews the case to decide the need for admission;
- (e) If the committee or subgroup making the review under [paragraph (d)](#d) of this section finds that the admission is not needed, it notifies the beneficiary's attending physician and gives him an opportunity to present his views before it makes a final decision on the need for the continued stay;
- (f) If the attending physician does not present additional information or clarification of the need for the admission, the decision of the committee or subgroup is final; and
- (g) If the attending physician presents additional information or clarification, at least two physician members of the committee review the need for the admission. If they find that the admission is not needed, their decision if final.

# §456.124. Notification of adverse decision.


The UR plan must provide that written notice of any adverse final decision on the need for admission under [§ 456.123 (e) through (g)](/cfr/42/456.123.md?p=e..g) is sent to—

- (a) The hospital administrator;
- (b) The attending physician;
- (c) The Medicaid agency;
- (d) The beneficiary; and
- (e) If possible, the next of kin or sponsor.

# §456.125. Time limits for admission review.


Except as required under [§ 456.127](/cfr/42/456.127.md), the UR plan must provide that review of each beneficiary's admission to the hospital is conducted—

- (a) Within one working day after admission, for an individual who is receiving Medicaid at that time; or
- (b) Within one working day after the hospital is notified of the application for Medicaid, for an individual who applies while in the hospital.

# §456.126. Time limits for final decision and notification of adverse decision.


Except as required under [§ 456.127](/cfr/42/456.127.md), the UR plan must provide that the committee makes a final decision on a beneficiary's need for admission and gives notice of an adverse final decision—

- (a) Within two working days after admission, for an individual who is receiving Medicaid at that time; or
- (b) Within two working days after the hospital is notified of the application for Medicaid, for an individual who applies while in the hospital.

# §456.127. Pre-admission review.


The UR plan must provide for review and final decision prior to admission for certain providers or categories of admissions that the UR committee designates under [§ 456.142(b)](/cfr/42/456.142.md?p=b) (4)(iii) to receive pre-admission review.


# §456.128. Initial continued stay review date.


The UR plan must provide that—

- (a) When a beneficiary is admitted to the hospital under the admission review requirements of this subpart, the committee assigns a specified date by which the need for his continued stay will be reviewed;
- (b) **The committee bases its assignment of the initial continued stay review date on—**
  - (1) The methods and criteria required to be described under [§ 456.129](/cfr/42/456.129.md);
  - (2) The individual's condition; and
  - (3) The individual's projected discharge date;
- (c)
  - (1) The committee uses any available appropriate regional medical care appraisal norms, such as those developed by abstracting services or third party payors, to assign the initial continued stay review date;
  - (2) These regional norms are based on current and statistically valid data on duration of stay in hospitals for patients whose characteristics, such as age and diagnosis, are similar to those of the individual whose case is being reviewed;
  - (3) If the committee uses norms to assign the initial continued stay review date, the number of days between the individual's admission and the initial continued stay review date is no greater than the number of days reflected in the 50th percentile of the norms. However, the committee may assign a later review date if it documents that the later date is more appropriate; and
- (d) The committee ensures that the initial continued stay review date is recorded in the individual's record.

# §456.129. Description of methods and criteria: Initial continued stay review date; close professional scrutiny; length of stay modification.


The UR plan must describe—

- (a) The methods and criteria, including norms if used, that the committee uses to assign the initial continued stay review date under [§ 456.128](/cfr/42/456.128.md).
- (b) The methods that the committee uses to select categories of admission to receive close professional scrutiny under [§ 456.123(b)](/cfr/42/456.123.md?p=b); and
- (c) The methods that the committee uses to modify an approved length of stay when the beneficiary's condition or treatment schedule changes.