§ 422.154 - External review.

(a) Basic rule. Except as provided in paragraph (c) of this section, each M+C organization must, for each M+C plan it operates, have an agreement with an independent quality review and improvement organization (review organization) approved by CMS to perform functions of the type described in part 466 of this chapter.

(b) Terms of the agreement. The agreement must be consistent with CMS guidelines and include the following provisions:

(1) Require that the organization—

(i) Allocate adequate space for use of the review organization whenever it is conducting review activities; and

(ii) Provide all pertinent data, including patient care data, at the time the review organization needs the data to carry out the reviews and make its determinations.

(2) Except in the case of complaints about quality, exclude review activities that CMS determines would duplicate review activities conducted as part of an approved accreditation process or as part of CMS monitoring.

(c) Exceptions. The requirement of paragraph (a) of this section does not apply for an M+C private fee-for-service plan or a non-network M+C MSA plan if the organization does not carry out utilization review with respect to the plan.