§ 476.100 - Use of norms and criteria.

§ 476.100 Use of norms and criteria.

(a) Use of norms. As specified in its contract, a QIO must use national, or where appropriate, regional norms in conducting review to achieve QIO contract objectives. However, with regard to determining the number of procedures selected for preadmission review, a QIO must use national admission norms.

(b) Use of criteria. In assessing the need for and appropriateness of an inpatient health care facility stay, a QIO must apply criteria to determine -

(1) The necessity for facility admission and continued stay (in cases of day outliers in hospitals under prospective payment);

(2) The necessity for surgery and other invasive diagnostic and therapeutic procedures; or

(3) The appropriateness of providing services at a particular health care facility or at a particular level of care. The QIO must determine whether the beneficiary requires the level of care received or whether a lower and less costly level of care would be equally effective.

(c) Establishment of criteria and standards. For the conduct of review a QIO must -

(1) Establish written criteria based upon typical patterns of practice in the QIO area, or use national criteria where appropriate; and

(2) Establish written criteria and standards to be used in conducting quality review studies.

(d) Variant criteria and standards. A QIO may establish specific criteria and standards to be applied to certain locations and facilities in the QIO area if the QIO determines that -

(1) The patterns of practice in those locations and facilities are substantially different from patterns in the remainder of the QIO area; and

(2) There is a reasonable basis for the difference which makes the variation appropriate.