[Code of Federal Regulations]
[Title 42, Volume 2]
[Revised as of October 1, 2002]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR422.154]

[Page 861]
 
                         TITLE 42--PUBLIC HEALTH
 
                             HUMAN SERVICES
 
PART 422--MEDICARE+CHOICE PROGRAM--Table of Contents
 
                      Subpart D--Quality Assurance
 
Sec. 422.154  External review.

    (a) Basic rule. Except as provided in paragraph (c) of this section, 
each M+C organization must, for each M+C plan it operates, have an 
agreement with an independent quality review and improvement 
organization (review organization) approved by CMS to perform functions 
of the type described in part 466 of this chapter.
    (b) Terms of the agreement. The agreement must be consistent with 
CMS guidelines and include the following provisions:
    (1) Require that the organization--
    (i) Allocate adequate space for use of the review organization 
whenever it is conducting review activities; and
    (ii) Provide all pertinent data, including patient care data, at the 
time the review organization needs the data to carry out the reviews and 
make its determinations.
    (2) Except in the case of complaints about quality, exclude review 
activities that CMS determines would duplicate review activities 
conducted as part of an approved accreditation process or as part of CMS 
monitoring.
    (c) Exceptions. The requirement of paragraph (a) of this section 
does not apply for an M+C private fee-for-service plan or a non-network 
M+C MSA plan if the organization does not carry out utilization review 
with respect to the plan.

[63 FR 35082, June 26, 1998, as amended at 65 FR 40323, June 29, 2000]