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) > 476.72—Review of the quality of care of risk-basis health maintenance organizations and competitive medical plans.

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

(a) (1) For purposes of a review under section 1154(a)(4) of the Act, a QIO 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-QIO 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 QIO's responsibilities, and sanctions on health care practitioners and providers.
[52 FR 37457, Oct. 7, 1987. Redesignated at 64 FR 66279, Nov. 24, 1999]