[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: 42CFR475.104]



[Page 463]

 

                         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 C_Utilization and Quality Control Quality Improvement 

                              Organizations

 

Sec.  475.104  Requirements for demonstrating ability to perform review.



    (a) A physician-sponsored or physician-access organization will be 

found capable of conducting review if CMS determines that the 

organization is able to set quantifiable performance objectives and 

perform the utilization and quality review functions established under 

section 1154 of the Social Security Act in an efficient and effective 

manner.

    (b) CMS will determine that the organization is capable of 

conducting utilization and quality review if--

    (1) The organization's proposed review system is adequate; and

    (2) The organization has available sufficient resources (including 

access to medical review skills) to implement that system; and

    (3) The organization's quantifiable objectives are acceptable.

    (c) CMS may consider prior similar review experience in making 

determinations under paragraph (b) of this section.

    (d) A State government that operates a Medicaid program will be 

considered incapable of performing utilization and quality review 

functions in an effective manner, unless the State demonstrates to the 

satisfaction of CMS that it will act with complete independence and 

objectivity.