C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 456—UTILIZATION CONTROL › Subpart C—Utilization Control: Hospitals

42 C.F.R. § 456.60

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 inpatient services in a hospital are or were needed.

(2) The certification must be made at the time of admission or, if an individual applies for assistance while in a hospital, 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 inpatient services in a hospital are needed.

(2) Recertifications must be made at least every 60 days after certification.

[46 FR 48561, Oct. 1, 1981]
Notes of Decisions
Cited in 4 cases, 2012–2016 · leading case: Culpeper Reg'l Hosp. v. Cynthia B. Jones, Dir., 767 S.E.2d 236 (Va. Ct. App. 2015).
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Culpeper Reg'l Hosp. v. Cynthia B. Jones, Dir., 767 S.E.2d 236 (Va. Ct. App. 2015). · cites it 3× “” The Hospital Manual issued by DMAS provides that “Medicaid requires that payment for certain covered services may be made to a provider of services only if there is a physician’s certification concerning the necessity of the services furnished.”
Chesapeake Hosp. Auth. v. Dep't of Med. Assistance Servs., 85 Va. Cir. 387 (Chesapeake Cir. Ct. 2012). · cites it 6× “such services, and (B) Such services were furnished under a plan established and periodically reviewed and evaluated by a physician, or, in the case of skilled nursing facility services or intermediate care facility services, a physician, or a nurse practitioner or clinical…”
Bon Secours St. Mary's Hosp. v. Cynthia B. Jones, Dir. (Va. Ct. App. 2016). · cites it 5× “2d 236, 238 (2015) (quoting 42 C.F.R. § 456.60 (a)(1)). Recertifications “must be made at least every 60 days after certification.”
Bon Secours St. Mary's Hosp. v. Dep't of Med. Assistance Servs., 88 Va. Cir. 111 (Richmond County Cir. Ct. 2014). · cites it 2× “The recertification requirements are found at 42 C.F.R. § 456.60 (b), which provides in relevant part: (1) A physician, or physician assistant or nurse practitioner .”
— 42 C.F.R. § 456.60(a) — 1 case
Bon Secours St. Mary's Hosp. v. Dep't of Med. Assistance Servs., 88 Va. Cir. 111 (Richmond County Cir. Ct. 2014). “The recertification requirements are found at 42 C.F.R. § 456.60 (b), which provides in relevant part: (1) A physician, or physician assistant or nurse practitioner .”
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