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.