---
kind: "range"
citation: "42 C.F.R. §§ 456.131–456.137"
title: "42"
from: "456.131"
to: "456.137"
count: 7
url: "https://uscodex.org/cfr/42/456.131..456.137"
---

# §456.131. Continued stay review required.


The UR plan must provide for a review of each beneficiary's continued stay in the hospital to decide whether it is needed, in accordance with the requirements of [§§ 456.132 through 456.137](/cfr/42/456.132..456.137.md).


# §456.132. Evaluation criteria for continued stay.


The UR plan must provide that—

- (a) **The committee develops written medical care criteria to assess the need for continued stay.**
- (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.**

# §456.133. Subsequent continued stay review dates.


The UR plan must provide that—

- (a) The committee assigns subsequent continued stay review dates in accordance with §§ [456.128](/cfr/42/456.128.md) and [456.134(a)](/cfr/42/456.134.md?p=a);
- (b) The committee assigns a subsequent review date each time it decides under [§ 456.135](/cfr/42/456.135.md) that the continued stay is needed; and
- (c) The committee ensures that each continued stay review date it assigns is recorded in the beneficiary's record.

# §456.134. Description of methods and criteria: Subsequent continued stay review dates; length of stay modification.


The UR plan must describe—

- (a) The methods and criteria, including norms if used, that the committee uses to assign subsequent continued stay review dates under [§ 456.133](/cfr/42/456.133.md); and
- (b) The methods that the committee uses to modify an approved length of stay when the beneficiary's condition or treatment schedule changes.

# §456.135. Continued stay review process.


The UR plan must provide that—

- (a) **Review of continued stay cases 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 reviews a beneficiary's continued stay on or before the expiration of each assigned continued stay review date;
- (c) For each continued stay of a beneficiary in the hospital, the committee, subgroup or designee reviews and evaluates the documentation described under [§ 456.111](/cfr/42/456.111.md) against the criteria developed under [§ 456.132](/cfr/42/456.132.md) and applies close professional scrutiny to cases selected under [§ 456.129(b)](/cfr/42/456.129.md?p=b);
- (d) If the committee, subgroup, or designee finds that a beneficiary's continued stay in the hospital is needed, the committee assigns a new continued stay review date in accordance with [§ 456.133](/cfr/42/456.133.md);
- (e) If the committee, subgroup, or designee finds that a continued stay case does not meet the criteria, the committee or a subgroup that includes at least one physician reviews the case to decide the need for continued stay;
- (f) If the committee or subgroup making the review under [paragraph (e)](#e) of this section finds that a continued stay is not needed, it notifies the beneficiary's attending physician and gives him an opportunity to present his reviews before it makes a final decision on the need for the continued stay;
- (g) If the attending physician does not present additional information or clarification of the need for the continued stay, the decision of the committee or subgroup is final; and
- (h) If the attending physician presents additional information or clarification, at least two physician members of the committee review the need for the continued stay. If they find that the beneficiary no longer needs inpatient hospital services, their decision is final.

# §456.136. Notification of adverse decision.


The UR plan must provide that written notice of any adverse final decision on the need for continued stay under [§ 456.135 (f) through (h)](/cfr/42/456.135.md?p=f..h) 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.

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


The UR plan must provide that—

- (a) The committee makes a final decision on a beneficiary's need for continued stay and gives notice under [§ 456.136](/cfr/42/456.136.md) of an adverse final decision within 2 working days after the assigned continued stay review dates, except as required under [paragraph (b)](#b) of this section.
- (b) If the committee makes an adverse final decision on a beneficiary's need for continued stay before the assigned review date, the committee gives notice under [§ 456.136](/cfr/42/456.136.md) within 2 working days after the date of the final decision.