[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: 42CFR476.100]



[Page 475]

 

                         TITLE 42--PUBLIC HEALTH

 

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

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 476_UTILIZATION AND QUALITY CONTROL REVIEW--Table of Contents

 

  Subpart C_Review Responsibilities of Utilization and Quality Control 

                Quality Improvement Organizations (QIOs)

 

Sec.  476.100  Use of norms and criteria.



    (a) Use of norms. As specified in its contract, a QIO must use 

national, or where appropriate, regional norms in conducting review to 

achieve QIO contract objectives. However, with regard to determining the 

number of procedures selected for preadmission review, a QIO must use 

national admission norms.

    (b) Use of criteria. In assessing the need for and appropriateness 

of an inpatient health care facility stay, a QIO must apply criteria to 

determine--

    (1) The necessity for facility admission and continued stay (in 

cases of day outliers in hospitals under prospective payment);

    (2) The necessity for surgery and other invasive diagnostic and 

therapeutic procedures; or

    (3) The appropriateness of providing services at a particular health 

care facility or at a particular level of care. The QIO must determine 

whether the beneficiary requires the level of care received or whether a 

lower and less costly level of care would be equally effective.

    (c) Establishment of criteria and standards. For the conduct of 

review a QIO must--

    (1) Establish written criteria based upon typical patterns of 

practice in the QIO area, or use national criteria where appropriate; 

and

    (2) Establish written criteria and standards to be used in 

conducting quality review studies.

    (d) Variant criteria and standards. A QIO may establish specific 

criteria and standards to be applied to certain locations and facilities 

in the QIO area if the QIO determines that--

    (1) The patterns of practice in those locations and facilities are 

substantially different from patterns in the remainder of the QIO area; 

and

    (2) There is a reasonable basis for the difference which makes the 

variation appropriate.