[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: 42CFR456.652]

[Page 307-308]
 
PART 456--UTILIZATION CONTROL--Table of Contents
 
  Subpart J--Penalty for Failure To Make a Satisfactory Showing of an 
           Effective Institutional Utilization Control Program
 
Sec. 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 
recipient:
    (1) Certification and recertification of the need for inpatient 
care, as specified in Secs. 456.60, 456.160, 456.360 and 456.481.
    (2) A plan of care established and periodically reviewed and 
evaluated by a physician, as specified in Secs. 456.80, 456.180, and 
456.481.
    (3) A continuous program of utilization review under which the 
admission of each recipient is reviewed or screened in accordance with 
section 1903(g)(1)(C) of the Act; and

[[Page 308]]

    (4) A regular program of reviews, including medical evaluations, and 
annual on-site reviews of the care of each recipient, as specified in 
Secs. 456.170, and 456.482 and subpart I of this part.
    (b) Annual on-site review requirements. (1) An agency meets the 
quarterly on-site review requirements of paragraph (a)(4) of this 
section for a quarter if it completes on-site reviews of each recipient 
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) 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 recipient 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 recipient 
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) 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) and (b) of this section apply with respect to 
recipients for whose care the agency intends to claim FFP even if the 
recipients receive care in a facility whose provider agreement has 
expired or been terminated.

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