---
kind: "range"
citation: "42 C.F.R. §§ 456.432–456.437"
title: "42"
from: "456.432"
to: "456.437"
count: 6
url: "https://uscodex.org/cfr/42/456.432..456.437"
---

# §456.432. Evaluation criteria for continued stay.


The UR plan must provide that—

- (a) **The group performing UR develops written criteria to assess the need for continued stay.**
- (b) **The group 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.**

# §456.433. Initial continued stay review date.


The UR plan must provide that—

- (a) 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;
- (b) 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)](/cfr/42/456.435.md?p=a);
- (c) **The initial continued stay review date is—**
  - (1) Not later than 6 months after admission; or
  - (2) Earlier than 6 months after admission, if indicated at the time of admission; and
- (d) The group performing UR insures that the initial continued stay review date is recorded in the beneficiary's record.

# §456.434. Subsequent continued stay review dates.


The UR plan must provide that—

- (a) The group performing UR assigns subsequent continued stay review dates in accordance with [§ 456.435](/cfr/42/456.435.md).
- (b) The group assigns a subsequent continued stay review date each time it decides under [§ 456.436](/cfr/42/456.436.md) that the continued stay is needed—
  - (1) At least every 6 months; or
  - (2) More frequently than every six months if indicated at the time of continued stay review; and
- (c) The group insures that each continued stay review date it assigns is recorded in the beneficiary's record.

# §456.435. Description of methods and criteria: Continued stay review dates.


The UR plan must describe the methods and criteria that the group performing UR uses to assign initial and subsequent continued stay review dates under §§ [456.433](/cfr/42/456.433.md) and [456.434](/cfr/42/456.434.md).


# §456.436. Continued stay review process.


The UR plan must provide that—

- (a) **Review of continued stay cases is conducted by—**
  - (1) The group performing UR; or
  - (2) A designee of the UR group;
- (b) The group or its 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 ICF, the group or its designee reviews and evaluates the documentation described under [§ 456.411](/cfr/42/456.411.md) against the criteria developed under [§ 456.432](/cfr/42/456.432.md) and applies close professional scrutiny to cases described under [§ 456.432(b)](/cfr/42/456.432.md?p=b);
- (d) 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](/cfr/42/456.434.md);
- (e) 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;
- (f) If the group 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 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;
- (g) 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;
- (h) If the attending physician or qualified Intellectual Disability professional presents additional information or clarification, the need for continued stay is reviewed by—
  - (1) The physician member(s) of the UR group, in cases involving a medical determination; or
  - (2) The UR group, in cases not involving a medical determination; and
    - (i) If the individuals performing the review under [paragraph (h)](#h) of this section find that the beneficiary no longer needs ICF services, their decision is final.

# §456.437. Notification of adverse decision.


The UR plan must provide that written notice of any adverse final decision on the need for continued stay under [§ 456.436 (g) through (i)](/cfr/42/456.436.md?p=g..i) is sent to—

- (a) The ICF administrator;
- (b) The attending physician;
- (c) The qualified Intellectual Disability professional, if applicable;
- (d) The Medicaid agency;
- (e) The beneficiary; and
- (f) If possible, the next of kin or sponsor.