42 C.F.R. § 456.360

Certification and recertification of need for inpatient care

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(a) Certification. (1) A physician must certify for each applicant or beneficiary that ICF services are or were needed.

(2) The certification must be made at the time of admission or, if an individual applies for assistance while in an ICF, before the Medicaid agency authorizes payment.

(b) Recertification. (1) A physician, or physician assistant or nurse practitioner (as defined in § 491.2 of this chapter) acting within the scope of practice as defined by State law and under the supervision of a physician, must recertify for each applicant or beneficiary that ICF services are needed.

(2) Recertification must be made at least—

(i) Every 12 months after certification in an institution for Individuals with Intellectual Disabilities or persons with related conditions; and

(ii) Every 60 days after certification in an ICF other than an institution for Individuals with Intellectual Disabilities or persons with related conditions.

[46 FR 48561, Oct. 1, 1981, as amended at 50 FR 33034, Aug. 16, 1985]

Notes of Decisions

Cited in 4 cases, 1985–2001 · leading case: State of Wisconsin, Department of Health and Social Services, Plaintiff v. Otis R. Bowen, Secretary of Health and Human

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State of Wisconsin, Department of Health and Social Services, Plaintiff v. Otis R. Bowen, Secretary of Health and Human (1986) ca7 · cites it 2× “” 42 C.F.R. § 456.360 (b). Wisconsin reads these provisions together as requiring only that a patient need at least the level of care for which he is certified; that is, it argues that a SNF-eertified patient can be placed in an ICF because the patient demonstrably needs that…”

Meyer v. Colorado Department of Social Services (1988) coloctapp “See 42 C.F.R. 456.360 and 42 C.F.R. 456.380. In continued stay reviews, however, the regulations only require the reviewing agency to evaluate documentation including the attending physician’s reasons and plan for continued stay if the physician believes continued stay is…”

Hawaii v. Heckler (1985) ca9 · cites it 2× “§ 1396b(g) and 42 C.F.R. § 456.360 to show that a physician has certified each patient’s need for ICF services and has recertified that need every 60 days.”

John/Jane Doe v. Jeb Bush (2001) ca11 “” 42 C.F.R. § 456.360 (a). Section 456.370 provides: (a) Before admission to an ICF .”

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