[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: 42CFR476.72]



[Page 467]

 

                         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.  476.72  Review of the quality of care of risk-basis health 



maintenance organizations and competitive medical plans.



    (a) (1) For purposes of a review under section 1154(a)(4) of the 

Act, a QIO must determine whether the quality of services (including 

both inpatient and outpatient services) provided by an HMO or CMP meets 

professionally recognized standards of health care, including whether 

appropriate health care services have not been provided or have been 

provided in inappropriate settings.

    (2) Paragraph (a)(1) of this section will not apply with respect to 

a contract year if another entity has been awarded a contract to perform 

those reviews under section 1154(a)(4)(C) of the Act.

    (b) For purposes of reviews under this section, non-QIO entities 

selected to perform these reviews under section 1154(a)(4)(C) of the Act 

are subject to the requirements of paragraph (a)(1) of this section 

and--

    (1) Part 476 of this chapter regarding acquisition, protection, and 

disclosure of peer review information; and

    (2) Part 1004 of Chapter V regarding a QIO's responsibilities, and 

sanctions on health care practitioners and providers.



[52 FR 37457, Oct. 7, 1987. Redesignated at 64 FR 66279, Nov. 24, 1999]



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