42 C.F.R. § 456.3
Statewide surveillance and utilization control program
The Medicaid agency must implement a statewide surveillance and utilization control program that—
(a) Safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments;
(b) Assesses the quality of those services;
(c) Provides for the control of the utilization of all services provided under the plan in accordance with subpart B of this part; and
(d) Provides for the control of the utilization of inpatient services in accordance with subparts C through I of this part.
Notes of Decisions
Cited in 9
cases, 1981–2020 · leading case: Cowan v. Myers
Cowan v. Myers (1986)
“340; see 42 C.F.R. § 456.3 .) In holding that the physician was not entitled to a hearing before implementation of the prior authorization order, we reasoned that "[a]lthough prior authorization inconveniences appellant it is applied not as a penalty, but as a means by which the…”
State Ex Rel. Department of Social & Rehabilitation Services v. Shodair Hospital (1995)
“42 C.F.R. § 456.3 (a) (1994). SRS is the state agency responsible for creating and managing the utilization program to "ensur[e] that services provided through the medicaid program are.”
Bader v. Wernert (2016)
“2, at 2 (quoting 42 C.F.R. § 456.3 ).) A provider on prepayment review is not paid for a submitted claim until a prepayment review analyst has reviewed the claim to verify its accuracy.”
Pressley Ridge Schools, Inc. v. Stottlemyer (1996)
“In July 1995, the Bureau developed the Surveillance and Utilization- Review of Services unit (hereinafter “SUR unit”), as required by 42 C.F.R. § 456.3 , to monitor and review Medicaid providers’ utilization of Medicaid services and to control inappropriate billing practices.”
Margulis v. Myers (1981)
“” ( 42 C.F.R. § 456.3 .) States are also required to “have a postpayment review process that—“(a) Allows State personnel to develop and review—(1) Recipient utilization profiles; (2) Provider service profiles; and (3) Exceptions criteria; and “(b) Identifies exceptions so that…”
Valley View Home of Beaumont, Inc. v. Department of Health Services (1983)
“§ 1396a(a)(30); see also 42 C.F.R. § 456.3 (1982).) Accordingly, the California Legislature has made certain utilization controls available to the Department of Health Services (Department) so that they may monitor and review the various kinds of health services provided to…”
Riverside Hospital, Inc. v. State Department of Social & Rehabilitation Services (1991)
“42 C.F.R. § 456.3 (1990) provides: “The Medicaid agency must implement a statewide surveillance and utilization control program that— (a) Safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments; (b) Assesses the quality of those…”
HCA Health Services of Kansas, Inc. v. State, Secretary of Kansas Department of Social & Rehabilitation Services (1994)
“42 C.F.R. § 456.3 (1993). Federal law also requires that, as part of the utilization and control process, the agency have procedures which, on a sample basis, evaluate the need, qual *152 ity, and timeliness of the Medicaid services.”
Jacobs v. Massachusetts Division of Medical Assistance (2020)
“" 42 C.F.R. § 456.3 (a). State law requires MassHealth to "verify the accuracy of bills submitted .”
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