§ 466.72 - Review of the quality of care of risk-basis health maintenance organizations and competitive medical plans.

Related Notices
- 98-4230. Proposed rule. 98-4230. Medicare Program; ``Without Fault'' and Waiver of Recovery from an Individual as it Applies to Medicare Overpayment Liability
- 94-21488. Final rule with comment period. 94-21488. Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and FY 1995 Rates; Final Rule DEPARTMENT OF HEALTH AND HUMAN SERVICES

Latest version.

(a) (1) For purposes of a review under section 1154(a)(4) of the Act, a PRO 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-PRO 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 PRO's responsibilities, and sanctions on health care practitioners and providers.

                    
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