[Code of Federal Regulations]
[Title 42, Volume 3, Parts 430 to End]
[Revised as of October 1, 1999]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR456.436]

[Page 301]
 
PART 456--UTILIZATION CONTROL--Table of Contents
 
      Subpart F--Utilization Control: Intermediate Care Facilities
 
Sec. 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 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 ICF, the group or 
its designee reviews and evaluates the documentation described under 
Sec. 456.411 against the criteria developed under Sec. 456.432 and 
applies close professional scrutiny to cases described under 
Sec. 456.432(b);
    (d) If the group or its designee finds that a recipient's continued 
stay in the ICF is needed, the group assigns a new continued stay review 
date in accordance with Sec. 456.434;
    (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) 
of this section finds that a continued stay is not needed, it notifies 
the recipient's attending physician or, in institutions for the mentally 
retarded, the recipient's qualified mental retardation 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 mental retardation 
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 mental retardation 
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) of 
this section find that the recipient no longer needs ICF services, their 
decision is final.