[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: 42CFR488.64]



[Page 671-672]

 

                         TITLE 42--PUBLIC HEALTH

 

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

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 488_SURVEY, CERTIFICATION, AND ENFORCEMENT PROCEDURES--Table of 

 

                     Subpart B_Special Requirements

 

Sec.  488.64  Remote facility variances for utilization review 



requirements.



    (a) As used in this section:

    (1) An ``available'' individual is one who:

    (i) Possesses the necessary professional qualifications;

    (ii) Is not precluded from participating by reason of financial 

interest in any such facility or direct responsibility for the care of 

the patients being reviewed or, in the case of a skilled nursing 

facility, employment by the facility; and

    (iii) Is not precluded from effective participation by the distance 

between the facility and his residence, office, or other place of work. 

An individual whose residence, office, or other place of work is more 

than approximately one hour's travel time from the facility shall be 

considered precluded from effective participation.

    (2) ``Adjacent facility'' means a health care facility located 

within a 50-mile radius of the facility which requests a variance.

    (b) The Secretary may grant a requesting facility a variance from 

the time frames set forth in Sec. Sec.  405.1137(d) of this chapter and 

482.30 as applicable, within which reviews all of cases must be 

commenced and completed, upon a showing satisfactory to the Secretary 

that the requesting facility has been unable to meet one or more of the 

requirements of Sec.  405.1137 of this chapter or Sec.  482.30 of this 

chapter, as applicable, by reason of insufficient medical and other 

professional personnel available to conduct the utilization review 

required by Sec.  405.1137 of this chapter or Sec.  482.30 of this 

chapter, as applicable.

    (c) The request for variance shall document the requesting 

facility's inability to meet the requirements for which a variance is 

requested and the facility's good faith efforts to comply with the 

requirements contained in Sec.  405.1137 of this chapter or Sec.  482.30 

of this chapter, as applicable.

    (d) The request shall include an assurance by the requesting 

facility that it will continue its good faith efforts to meet the 

requirements contained in Sec.  405.1137 of this chapter or Sec.  482.30 

of this chapter, as applicable.

    (e) A revised utilization review plan for the requesting facility 

shall be submitted concurrently with the request for a variance. The 

revised plan shall specify the methods and procedures which the 

requesting facility will use, if a variance is granted, to assure:

    (1) That effective and timely control will be maintained over the 

utilization of services; and

    (2) That reviews will be conducted so as to improve the quality of 

care provided to patients.

    (f) The request for a variance shall include:

    (1) The name, location, and type (e.g., hospital, skilled nursing 

facility) of the facility for which the variance is requested;

    (2) The total number of patient admissions and average daily patient 

census at the facility within the previous six months;

    (3) The total number of title XVIII and title XIX patient admissions 

and the average daily patient census of title XVIII and title XIX 

patients in the facility within the previous six months;



[[Page 672]]



    (4) As relevant to the request, the names of all physicians on the 

active staff of the facility and the names of all other professional 

personnel on the staff of the facility, or both;

    (5) The name, location, and type of each adjacent facility (e.g., 

hospital, skilled nursing facility);

    (6) The distance and average travel time between the facility and 

each adjacent facility;

    (7) As relevant to the request, the location of practice of 

available physicians and the estimated number of other available 

professional personnel, or both (see paragraph (a)(1)(iii) of this 

section);

    (8) Documentation by the facility of its attempt to obtain the 

services of available physicians or other professional personnel, or 

both; and

    (9) A statement of whether a QIO exists in the area where the 

facility is located.

    (g) The Secretary shall promptly notify the facility of the action 

taken on the request. Where a variance is in effect, the validation of 

utilization review pursuant to Sec.  405.1137 of this chapter or Sec.  

482.30 shall be made with reference to the revised utilization review 

plan submitted with the request for variance.

    (h) The Secretary, in granting a variance, will specify the period 

for which the variance has been granted; such period will not exceed one 

year. A request for a renewal shall be submitted not later than 30 days 

prior to the expiration of the variance and shall contain all 

information required by paragraphs (c), (d), and (f) of this section. 

Renewal of the variance will be contingent upon the facility's 

continuing to meet the provisions of this section.



[40 FR 30818, July 23, 1975. Redesignated at 42 FR 52826, Sept. 30, 

1977; 51 FR 22041, June 17, 1986; 51 FR 27847, Aug. 4, 1986; 51 FR 

43197, Dec. 1, 1986. Redesignated and amended at 53 FR 23100, June 17, 

1988]