[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: 42CFR476.102]



[Page 475-476]

 

                         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.  476.102  Involvement of health care practitioners other than 



physicians.



    (a) Basic requirement. Except as provided in paragraph (b) of this 

section, a QIO must meet the following requirements:

    (1) Consult with the peers of the practitioners who furnish the 

services under review if the QIO reviews care and services delivered by 

health care practitioners other than physicians.

    (2) Assure that in determinations regarding medical necessity of 

services or the quality of the services they furnish, these 

practitioners are involved in--

    (i) Developing QIO criteria and standards;

    (ii) Selecting norms to be used; and

    (iii) Developing review mechanisms for care furnished by their 

peers.

    (3) Ensure that an initial denial determination or a change as a 

result of DRG validation of services provided by a health care 

practitioner other than a physician is made by a physician only after 

consultation with a peer of that practitioner. Initial denial 

determinations and changes as a result of DRG validations must be made 

only by a physician or dentist.

    (b) Exception. The requirements of paragraph (a) of this section do 

not apply if--

    (1) The QIO has been unable to obtain a roster of peer practitioners 

available to perform review; or

    (2) The practitioners are precluded from performing review because 

they participated in the treatment of the patient, the patient is a 

relative, or the practitioners have a financial interest



[[Page 476]]



in the health care facility as described in Sec.  466.98(d).

    (c) Peer involvement in quality review studies. Practitioners must 

be involved in the design of quality review studies, development of 

criteria, and actual conduct of studies involving their peers.

    (d) Consultation with practitioners other than physicians. To the 

extent practicable, a QIO must consult with nurses and other 

professional health care practitioners (other than physicians defined in 

1861(r) (1) and (2) of the Act) and with representatives of 

institutional and noninstitutional providers and suppliers with respect 

to the QIO's responsibility for review.



[50 FR 15330, Apr. 17, 1985; 50 FR 41886, Oct. 16, 1985. Redesignated at 

64 FR 66279, Nov. 24, 1999]