CFR > Title 42 - Public Health > CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES > SUBCHAPTER F—QUALITY IMPROVEMENT ORGANIZATIONS (parts 475 to 481) > PART 476—UTILIZATION AND QUALITY CONTROL REVIEW > SUBPART C—Review Responsibilities of Utilization and Quality Control Quality Improvement Organizations (QIOs) (§476.70 to §476.104) > 476.70—Statutory bases and applicability.

476.70—Statutory bases and applicability.

(a) Statutory basis. Sections 1154, 1866(a)(1)(F) and 1886(f)(2) of the Act require that a QIO review those services furnished by physicians, other health care professionals, providers and suppliers as specified in its contract with the Secretary. Section 1154(a)(4) of the Act requires QIOs, or, in certain circumstances, non-QIO entities, to perform quality of care reviews of services furnished under risk-basis contracts by health maintenance organizations (HMOs) and competitive medical plans (CMPs) that are covered under subpart C of part 417 of this chapter.
(b) Applicability. The regulations in this subpart apply to review conducted by a QIO and its subcontractors. Section 466.72 of this part also applies, for purposes of quality of care reviews under section 1154(a)(4) of the Act, to non-QIO entities that enter into contracts to perform reviews of services furnished under risk-basis contracts by HMOs and CMPs under subpart C of part 417 of this chapter.
[52 FR 37457, Oct. 7, 1987. Redesignated at 64 FR 66279, Nov. 24, 1999]