CMS SOM App. A, Tag A-0654

A UR committee consisting of two or more practitioners must carry out the UR function.

At least two of the members of the committee must be doctors of medicine or osteopathy.

The other members may be any of the other types of practitioners specified in

§482.12(c)(1).

(1) Except as specified in paragraphs (b)(2) and (3) of this section, the UR

committee must be one of the following:

(i) A staff committee of the institution;

(ii) A group outside the institution--

(A) Established by the local medical society and some or all of the

hospitals in the locality; or

(B) Established in a manner approved by CMS.

(2) If, because of the small size of the institution, it is impracticable to have a

properly functioning staff committee, the UR committee must be established as

specified in paragraph (b)(1)(ii) of this section.

(3) The committee or group’s reviews may not be conducted by any individual

who--

(i) Has a direct financial interest (for example, an ownership interest) in that

hospital; or

(ii) Was professionally involved in the care of the patient whose case is being

reviewed.

Survey Procedures §482.30(b)

• Determine the composition of the UR committee;

• Determine that the governing body has delegated to the UR committee the authority and

responsibility to carry out the UR function;

• Verify that small hospitals delegate the UR function to an outside group if it is

impractical to have a staff committee;

• Ascertain that committee members are not financially involved in the hospital (ownership

of 5 percent or greater) nor participants in the development or execution of the patient’s

treatment plan.