[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR456.135]



[Page 347-348]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 456_UTILIZATION CONTROL--Table of Contents

 

                Subpart C_Utilization Control: Hospitals

 

Sec.  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 recipient's 

continued stay on or before the expiration of each assigned continued 

stay review date;

    (c) For each continued stay of a recipient in the hospital, the 

committee,



[[Page 348]]



subgroup or designee reviews and evaluates the documentation described 

under Sec.  456.111 against the criteria developed under Sec.  456.132 

and applies close professional scrutiny to cases selected under Sec.  

456.129(b);

    (d) If the committee, subgroup, or designee finds that a recipient's 

continued stay in the hospital is needed, the committee assigns a new 

continued stay review date in accordance with Sec.  456.133;

    (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 recipient'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 recipient no 

longer needs inpatient hospital services, their decision is final.