---
kind: "section"
citation: "42 C.F.R. § 456.652"
title: "42"
number: "456.652"
heading: "Requirements for an effective utilization control program."
url: "https://uscodex.org/cfr/42/456.652"
---

# §456.652. Requirements for an effective utilization control program.

- (a) **General requirements.** In order to avoid a reduction in FFP, the Medicaid agency must make a satisfactory showing to the Administrator, in each quarter, that it has met the following requirements for each beneficiary:
  - (1) Certification and recertification of the need for inpatient care, as specified in §§ [456.60](/cfr/42/456.60.md), [456.160](/cfr/42/456.160.md), [456.360](/cfr/42/456.360.md) and [456.481](/cfr/42/456.481.md).
  - (2) A plan of care established and periodically reviewed and evaluated by a physician, as specified in §§ [456.80](/cfr/42/456.80.md), [456.180](/cfr/42/456.180.md), and [456.481](/cfr/42/456.481.md).
  - (3) A continuous program of utilization review under which the admission of each beneficiary is reviewed or screened in accordance with section 1903(g)(1)(C) of the Act; and
  - (4) A regular program of reviews, including medical evaluations, and annual on-site reviews of the care of each beneficiary, as specified in §§ [456.170](/cfr/42/456.170.md), and [456.482](/cfr/42/456.482.md) and [subpart I](/cfr/42/subpartI.md) of this part.
- (b) **Annual on-site review requirements.**
  - (1) An agency meets the quarterly on-site review requirements of [paragraph (a)(4)](#a-4) of this section for a quarter if it completes on-site reviews of each beneficiary in every facility in the State, and in every State-owned facility regardless of location, by the end of the quarter in which a review is required under [paragraph (b)(2)](#b-2) of this section.
  - (2) An on-site review is required in a facility by the end of a quarter if the facility entered the Medicaid program during the same calendar quarter 1 year earlier or has not been reviewed since the same calendar quarter 1 year earlier. If there is no Medicaid beneficiary in the facility on the day a review is scheduled, the review is not required until the next quarter in which there is a Medicaid beneficiary in the facility.
  - (3) If a facility is not reviewed in the quarter in which it is required to be reviewed under [paragraph (b)(2)](#b-2) of this section, it will continue to require a review in each subsequent quarter until the review is performed.
  - (4) The requirement for an on-site review in a given quarter is not affected by the addition or deletion of a level of care in a facility's provider agreement.
- (c) **Facilities without valid provider agreements.** The requirements of paragraphs [(a)](#a) and [(b)](#b) of this section apply with respect to beneficiaries for whose care the agency intends to claim FFP even if the beneficiaries receive care in a facility whose provider agreement has expired or been terminated.

## Notes

### Amendments

[44 FR 56338, Oct. 1, 1979, as amended at 46 FR 48561, Oct. 1, 1981; 61 FR 38399, July 24, 1996]

### Authority

Authority: Secs. 1102 and 1903(g) of the Social Security Act (42 U.S.C. 1302 and 1396 b(g)).

### Source

Source: 44 FR 56338, Oct. 1, 1979, unless otherwise noted.

### Authority

Authority: 42 U.S.C. 1302.

### Source

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

### Amendments

[44 FR 56338, Oct. 1, 1979, as amended at 46 FR 48561, Oct. 1, 1981; 61 FR 38399, July 24, 1996]