[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: 42CFR475.1]



[Page 461]

 

                         TITLE 42--PUBLIC HEALTH

 

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

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 475_QUALITY IMPROVEMENT ORGANIZATIONS--Table of Contents

 

                      Subpart A_General Provisions

 

Sec.  475.1  Definitions.





    For purposes of this part:

    Five percent or more owner means a person (including, where 

appropriate, a corporation) who:

    (a) Has an ownership interest of 5 percent or more;

    (b) Has an indirect ownership interest equal to 5 percent or more;

    (c) Has a combination of direct and indirect ownership interests 

(the possession of equity in the capital, the stock, or the profits of 

an entity) equal to 5 percent or more; or

    (d) Is the owner of an interest of 5 percent or more in any 

obligation secured by an entity, if the interest equals at least 5 

percent of the value of the property or assets of the entity.

    Health care facility means an institution that directly provides or 

supplies health care services for which payment may be made in whole or 

in part under Title XVIII of the Act. A health care facility may be a 

hospital, skilled nursing facility, home health agency, free-standing 

ambulatory surgical center, or outpatient facility or any other entity 

which provides or supplies direct care to Medicare beneficiaries.

    Managing employee means a general manager, business manager, 

administrator, director or other individual who exercises operational or 

managerial control over the entity or organization, or who, directly or 

indirectly, conducts the day-to-day operations of the entity or 

organization.

    Payor organization means any organization, other than a self-insured 

employer, which makes payments directly or indirectly to health care 

practitioners or providers whose health care services are reviewed by 

the organization or would be reviewed by the organization if it entered 

into a QIO contract. ``Payor organization'' also means any organization 

which is affiliated with any entity which makes payments as described 

above, by virtue of the organization having two or more governing body 

members who are also either governing body members, officers, partners, 

5 percent or more owners or managing employees in a health maintenance 

organization or competitive medical plan.

    Physician means:

    (1) A doctor of medicine or osteopathy licensed under State law to 

practice medicine, surgery, or osteopathy in the State in which the QIO 

is located;

    (2) An intern, resident, or Federal Government employee authorized 

under State or Federal law to practice medicine, surgery, or osteopathy 

in the QIO area; and

    (3) An individual licensed to practice medicine in American Samoa, 

the Northern Mariana Islands, and the Trust Territory of the Pacific 

Islands.



[43 FR 32085, July 24, 1978, as amended at 49 FR 7206, Feb. 27, 1984. 

Redesignated at 50 FR 15327, Apr. 17, 1985, and amended at 50 FR 15328, 

Apr. 17, 1985; 51 FR 43197, Dec. 1, 1986. Redesignated at 64 FR 66279, 

Nov. 24, 1999]



Subpart B [Reserved]



[[Page 462]]