[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: 42CFR476.98]



[Page 474-475]

 

                         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.  476.98  Reviewer qualifications and participation.



    (a) Peer review by physician. (1) Except as provided in paragraph 

(a)(2) of this section, each person who makes an initial denial 

determination about services furnished or proposed to be furnished by a 

licensed doctor of medicine or osteopathy or by a doctor of dentistry 

must be respectively another licensed doctor of medicine or osteopathy 

or of dentistry with active staff privileges in one or more hospitals in 

the QIO area.

    (2) If a QIO determines that peers are not available to make initial 

denial determinations, a doctor of medicine or osteopathy may make 

denial determinations for services ordered or performed by a doctor in 

any of the three specialties.

    (3) For purposes of paragraph (a)(1) of this section, individuals 

authorized to practice medicine in American Samoa, the Northern Mariana 

Islands, and the Trust Territory of the Pacific Islands as ``medical 

officers'' may make determinations on care ordered or furnished by their 

peers but not on care ordered or furnished by licensed doctors of 

medicine or osteopathy.

    (b) Peer review by health care practitioners other than physicians. 

Health care practitioners other than physicians may review services 

furnished by other practitioners in the same professional field.

    (c) DRG validation review. Decisions about procedural and diagnostic 

information must be made by physicians. Technical coding issues must be 

reviewed by individuals with training and experience in ICD-9-CM coding.

    (d) Persons excluded from review. (1) A person may not review health 

care



[[Page 475]]



services or make initial denial determinations or changes as a result of 

DRG validations if he or she, or a member of his or her family--

    (i) Participated in developing or executing the beneficiary's 

treatment plan;

    (ii) Is a member of the beneficiary's family; or

    (iii) Is a governing body member, officer, partner, 5 percent or 

more owner, or managing employee in the health care facility where the 

services were or are to be furnished.

    (2) A member of a reviewer's family is a spouse (other than a spouse 

who is legally separated under a decree of divorce or separate 

maintenance), child (including a legally adopted child), grandchild, 

parent, or grandparent.