[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR438.310]



[Page 232-233]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

                    Subpart E_External Quality Review

 

Sec.  438.310  Basis, scope, and applicability.



    Source: 68 FR 3635, Jan. 24, 2003, unless otherwise noted.





    (a) Statutory basis. This subpart is based on sections 1932(c)(2), 

1903(a)(3)(C)(ii), and 1902(a)(4) of the Act.

    (b) Scope. This subpart sets forth requirements for annual external 

quality reviews of each contracting managed care organization (MCO) and 

prepaid inpatient health plan (PIHP), including--

    (1) Criteria that States must use in selecting entities to perform 

the reviews;



[[Page 233]]



    (2) Specifications for the activities related to external quality 

review;

    (3) Circumstances under which external quality review may use the 

results of Medicare quality reviews or private accreditation reviews; 

and

    (4) Standards for making available the results of the reviews.

    (c) Applicability. The provisions of this subpart apply to MCOs, 

PIHPs, and to health insuring organizations (HIOs) that began on or 

after January 1, 1986 that the statute does not explicitly exempt from 

requirements in section 1903(m) of the Act.