[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: 42CFR438.354]



[Page 233-234]

 

                         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.  438.354  Qualifications of external quality review organizations.



    (a) General rule. The State must ensure that an EQRO meets the 

requirements of this section.

    (b) Competence. The EQRO must have at a minimum the following:

    (1) Staff with demonstrated experience and knowledge of--

    (i) Medicaid recipients, policies, data systems, and processes;

    (ii) Managed care delivery systems, organizations, and financing;



[[Page 234]]



    (iii) Quality assessment and improvement methods; and

    (iv) Research design and methodology, including statistical 

analysis.

    (2) Sufficient physical, technological, and financial resources to 

conduct EQR or EQR-related activities.

    (3) Other clinical and nonclinical skills necessary to carry out EQR 

or EQR-related activities and to oversee the work of any subcontractors.

    (c) Independence. The EQRO and its subcontractors are independent 

from the State Medicaid agency and from the MCOs or PIHPs that they 

review. To qualify as ``independent''--

    (1) A State agency, department, university, or other State entity 

may not have Medicaid purchasing or managed care licensing authority; 

and

    (2) A State agency, department, university, or other State entity 

must be governed by a Board or similar body the majority of whose 

members are not government employees.

    (3) An EQRO may not--

    (i) Review a particular MCO or PIHP if either the EQRO or the MCO or 

PIHP exerts control over the other (as used in this paragraph, 

``control'' has the meaning given the term in 48 CFR 19.101) through--

    (A) Stock ownership;

    (B) Stock options and convertible debentures;

    (C) Voting trusts;

    (D) Common management, including interlocking management; and

    (E) Contractual relationships.

    (ii) Deliver any health care services to Medicaid recipients;

    (iii) Conduct, on the State's behalf, ongoing Medicaid managed care 

program operations related to oversight of the quality of MCO or PIHP 

services, except for the related activities specified in Sec.  438.358; 

or

    (iv) Have a present, or known future, direct or indirect financial 

relationship with an MCO or PIHP that it will review as an EQRO.