42 C.F.R. §§ 456.401–456.438

The State plan must provide that—

The State plan must specify the method used to perform UR, which may be—

How UR is performed in the ICF; and

The UR plan must include a written description of who performs UR in the ICF.

UR must be performed using a method specified under § 456.401(b) by a group of professional personnel that includes—

The group performing UR may not include any individual who—

The UR support responsibilities of the ICF's administrative staff; and

The name of the qualified Intellectual Disability professional (as defined under § 442.401 of this subchapter), if applicable.

Date of admission, and dates of application for and authorization of Medicaid benefits if application is made after admission.

The plan of care required under § 456.372;

Initial and subsequent continued stay review dates described under §§ 456.433 and 456.434.

Reasons and plan for continued stay, if the attending physician or qualified Intellectual Disability professional believes continued stay is necessary.

The types of records that are kept by the group performing UR; and

The type and frequency of reports made by the UR group, and arrangements for distribution of the reports to appropriate individuals.

The UR plan must provide for a review of each beneficiaries continued stay in the ICF at least every 6 months to decide whether it is needed.

The UR plan requirement for continued stay review may be met by—

When a beneficiary is admitted to the ICF under admission review requirements of this subpart, the group performing UR assigns a specified date by which the need for his continued stay will be reviewed;

The group performing UR bases its assignment of the initial continued stay review date on the methods and criteria required to be described under § 456.435(a);

The group performing UR insures that the initial continued stay review date is recorded in the beneficiary's record.

The group performing UR assigns subsequent continued stay review dates in accordance with § 456.435.

The group assigns a subsequent continued stay review date each time it decides under § 456.436 that the continued stay is needed—

The group insures that each continued stay review date it assigns is recorded in the beneficiary's record.

The group or its designee reviews a beneficiary's continued stay on or before the expiration of each assigned continued stay review date.

For each continued stay of a beneficiary in the ICF, the group or its designee reviews and evaluates the documentation described under § 456.411 against the criteria developed under § 456.432 and applies close professional scrutiny to cases described under § 456.432(b);

If the group or its designee finds that a beneficiary's continued stay in the ICF is needed, the group assigns a new continued stay review date in accordance with § 456.434;

If the group or its designee finds that a continued stay case does not meet the criteria, the group or a subgroup that includes at least one physician reviews the case to decide the need for continued stay;

If the group 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 physician or, in institutions for individuals with intellectual disabilities, the beneficiary's qualified Intellectual Disability professional, within 1 working day of its decision, and gives him 2 working days from the notification date to present his views before it makes a final decision on the need for the continued stay;

If the attending physician or qualified Intellectual Disability professional does not present additional information or clarification of the need for the continued stay, the decision of the UR group is final;

If the attending physician or qualified Intellectual Disability professional presents additional information or clarification, the need for continued stay is reviewed by—

The ICF administrator;

The attending physician;

The qualified Intellectual Disability professional, if applicable;

The Medicaid agency;

The beneficiary; and

If possible, the next of kin or sponsor.