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Notes

42 C.F.R. §§ 456.232–456.238

7 sections in range

§456.232. Evaluation criteria for continued stay.

42 C.F.R. § 456.232

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.
Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45266, Sept. 29, 1978, unless otherwise noted.

§456.233. Initial continued stay review date.

42 C.F.R. § 456.233

The UR plan must provide that—
(a)
When a beneficiary is admitted to the mental hospital under admission review requirements of this subpart, the committee assigns a specified date by which the need for his continued stay will be reviewed;
(b)
If an individual applies for Medicaid while in the mental hospital, the committee assigns the initial continued stay review date within 1 working day after the mental hospital is notified of the application for Medicaid;
(c)
The committee bases its assignment of the initial continued stay review date on—
(1)
The methods and criteria required to be described under § 456.235(a);
(2)
The individual's condition; and
(3)
The individual's projected discharge date;
(d)
(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 norms are based on current and statistically valid data on duration of stay in mental hospitals for patients whose characteristics, such as age and diagnosis, are similar to those of the individual whose need for continued stay 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;
(e)
The initial continued stay review date is not in any case later than 30 days after admission of the individual or notice to the mental hospital of his application for Medicaid; and
(f)
The committee insures that the initial continued stay review date is recorded in the individual's record.
Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45266, Sept. 29, 1978, unless otherwise noted.

§456.234. Subsequent continued stay review dates.

42 C.F.R. § 456.234

The UR plan must provide that—
(a)
The committee assigns subsequent continued stay review dates in accordance with §§ 456.235(a) and 456.233;
(b)
The committee assigns a subsequent continued stay review date at least every 90 days each time it decides under § 456.236 that the continued stay is needed; and
(c)
The committee insures that each continued stay review date it assigns is recorded in the beneficiary's record.
Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45266, Sept. 29, 1978, unless otherwise noted.

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

42 C.F.R. § 456.235

The UR plan must describe—
(a)
The methods and criteria, including norms if used, that the committee uses to assign initial and subsequent continued stay review dates under §§ 456.233 and 456.234 of this subpart; and
(b)
The methods that the committee uses to modify an approved length of stay when the beneficiary's condition or treatment schedule changes.
Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45266, Sept. 29, 1978, unless otherwise noted.

§456.236. Continued stay review process.

42 C.F.R. § 456.236

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 mental hospital, the committee, subgroup or designee reviews and evaluates the documentation described under § 456.211 against the criteria developed under § 456.232 and applies close professional scrutiny to cases described under § 456.232(b).
(d)
If the committee, subgroup or designee finds that a beneficiary's continued stay in the mental hospital is needed, the committee assigns a new continued stay review date in accordance with § 456.234;
(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) of this section finds that a continued stay is not needed, it notifies the beneficiary's attending or staff physician and gives him an opportunity to present his views before it makes a final decision on the need for the continued stay;
(g)
If the attending or staff 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 or staff physician presents additional information or clarification, at least two physician members of the committee, one of whom is knowledgeable in the treatment of mental diseases, review the need for the continued stay. If they find that the beneficiary no longer needs inpatient mental hospital services, their decision is final.
Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45266, Sept. 29, 1978, unless otherwise noted.

§456.237. Notification of adverse decision.

42 C.F.R. § 456.237

The UR plan must provide that written notice of any adverse final decision on the need for continued stay under § 456.236 (f) through (h) is sent to—
(a)
The hospital administrator;
(b)
The attending or staff physician;
(c)
The Medicaid agency;
(d)
The beneficiary; and
(e)
If possible, the next of kin or sponsor.
Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45266, Sept. 29, 1978, unless otherwise noted.

§456.238. Time limits for final decision and notification of adverse decision.

42 C.F.R. § 456.238

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 § 456.237 of an adverse decision within 2 working days after the assigned continued stay review date, except as required under paragraph (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 § 456.237 within 2 working days after the date of the final decision.
Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45266, Sept. 29, 1978, unless otherwise noted.