[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: 42CFR438.358]



[Page 234-235]

 

                         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.  438.358  Activities related to external quality review.



    (a) General rule. The State, its agent that is not an MCO or PIHP, 

or an EQRO may perform the mandatory and optional EQR-related activities 

in this section.

    (b) Mandatory activities. For each MCO and PIHP, the EQR must use 

information from the following activities:

    (1) Validation of performance improvement projects required by the 

State to comply with requirements set forth in Sec.  438.240(b)(1) and 

that were underway during the preceding 12 months.

    (2) Validation of MCO or PIHP performance measures reported (as 

required by the State) or MCO or PIHP performance measure calculated by 

the State during the preceding 12 months to comply with requirements set 

forth in Sec.  438.240(b)(2).

    (3) A review, conducted within the previous 3-year period, to 

determine the MCO's or PIHP's compliance with standards (except with 

respect to standards under Sec. Sec.  438.240(b)(1) and (2), for the 

conduct of performance improvement projects and calculation of 

performance measures respectively) established by the State to comply 

with the requirements of Sec.  438.204(g).

    (c) Optional activities. The EQR may also use information derived 

during the



[[Page 235]]



preceding 12 months from the following optional activities:

    (1) Validation of encounter data reported by an MCO or PIHP.

    (2) Administration or validation of consumer or provider surveys of 

quality of care.

    (3) Calculation of performance measures in addition to those 

reported by an MCO or PIHP and validated by an EQRO.

    (4) Conduct of performance improvement projects in addition to those 

conducted by an MCO or PIHP and validated by an EQRO.

    (5) Conduct of studies on quality that focus on a particular aspect 

of clinical or nonclinical services at a point in time.

    (d) Technical assistance. The EQRO may, at the State's direction, 

provide technical guidance to groups of MCOs or PIHPs to assist them in 

conducting activities related to the mandatory and optional activities 

that provide information for the EQR.