CMS SOM App. A, Tag A-0653

The provisions of this section apply except in either of the following

circumstances:

(1) A Utilization and Quality Control Quality Improvement Organization (QIO) has

assumed binding review for the hospital.

(2) CMS has determined that the UR procedures established by the State under title

XIX of the Act are superior to the procedures required in this section, and has required

hospitals in that State to meet the UR plan requirements under §§456.50 through 456.245

of this chapter.

Interpretive Guidelines §482.30(a)

The regulation permits two exceptions to the requirement for a hospital UR plan: (1) where the

hospital has an agreement with a QIO under contract with the Secretary to assume binding

review for the hospital or; (2) where CMS has determined that UR procedures established by the

State under Medicaid are superior to the UR requirements for the Medicare program and has

required hospitals in that State to meet the UR requirements for the Medicaid program at 42 CFR

456.50 through 456.245.

According to the regulation at 42 CFR 476.86(e), QIO review and monitoring activities fulfill the

requirements for compliance activities of State Survey Agencies under §1861(k) of the Social

Security Act (Act). The statutory requirements for utilization review at §1861(k) of the Act are

reiterated in the UR CoP at 42 CFR 482.30. Therefore, a hospital meets the exception

requirements of 42 CFR 482.30 if a QIO has assumed binding review for the hospital. (The

hospital may not make requests for work to be performed by the QIO that goes beyond the scope

of the QIO’s contract with the Secretary.)

The regulation at 42 CFR 489.20(e) requires a hospital to maintain an agreement with a QIO to

review the admissions, quality, appropriateness, and diagnostic information related to inpatient

services for Medicare patients, if there is a QIO with a contract with CMS in the area where the

hospital is located.

CMS anticipates that most hospitals comply with the UR CoP by means of the QIO exception.

With regard to the second exception, CMS would have to determine that UR procedures

established by a State under Medicaid are superior to the UR requirements for Medicare.

Currently no UR plans established by a State under Medicaid have been approved as exceeding

the requirements under Medicare and required for hospital compliance with the Medicare UR

CoP within that State. In the event that CMS approves a State’s Medicaid UR process for

compliance with the Medicare UR CoP, CMS will advise the affected State Survey Agency.

Survey Procedures §482.30(a)

Surveyors are to verify either that the hospital:

• Has its own UR plan in place and that it meets the regulatory requirements; or

• If it does not have its own UR plan, that it has an agreement with the QIO that provides

for binding UR review. Surveyors should ask to see the signed, dated agreement. If the

hospital has an agreement with a QIO, it is not necessary for surveyors to assess the

remaining UR standards.

It is not necessary for SAs to conduct routine surveys for compliance with the provider

agreement requirement to have a QIO agreement. However, a hospital that does not satisfy the

UR CoP through either its own program or a QIO agreement may be cited for violating the UR

CoP at the condition level.