• 42 USC Sec 1302 Analyses of Medicare and Medicaid rules and regulations on small rural hospitals
• 42 USC Sec. 1320c Purpose: Utilization Review
• 42 USC Sec. 1320c-1 Utilization and quality control peer review organization defined
• 42 USC Sec. 1320c-2 Contracts with utilization and quality control peer review organizations
• 42 USC Sec. 1320c-3 Functions of peer review organizations
• 42 USC Sec. 1320c-4 Right to hearing and judicial review
• 42 USC Sec. 1320c-5 Obligations of health care practitioners and providers of health careservices
• 42 USC Sec. 1320c-6 Limitation on liability
• 42 USC Sec. 1320c-7 Application of this part to certain State programs
• 42 USC Sec. 1320c-8 Authorization for use of certain funds to administer provisions of this part
• 42 USC Sec. 1320c-9 Prohibition against disclosure of information
• 42 USC Sec. 1320c-10 Annual reports
• 42 USC Sec. 1320c-11 Exemptions of Christian Science sanatoriums
• 42 USC Sec. 1320c-12 American Samoa, Northern Mariana Islands, andPacific Islands
• 42 USC Sec. 1320c-13 100 percent peer review for certain surgical procedures
• 42 USC Sec. 1395hh Authority to prescribe regulations
• 42 USC Sec. 11101 Findings
• 42 USC Sec. 11111 Professional review
• 42 USC Sec. 11112 Standards for professional review actions
• 42 USC Sec. 11113 Payment of reasonable attorneys' fees and costs
• 42 USC Sec. 11114 Guidelines of Secretary
• 42 USC Sec. 11115 Construction
• 42 USC Sec. 11131 Requiring reports on medical malpractice payments
• 42 USC Sec. 11132 Reporting of sanctions taken by Boards
• 42 USC Sec. 11133 Reporting of certain professional review actions
• 42 USC Sec. 11134 Form of reporting
• 42 USC Sec. 11135 Duty of hospitals to obtain information
• 42 USC Sec. 11136 Disclosure and correction of information
• 42 USC Sec. 11137 Miscellaneous provisions
• 42 USC Sec. 11151 Definitions
• 42 USC Sec. 11152 Reports and memoranda of understanding
• 42 USC Sec. 13031 Child abuse reporting

• Health Care Programs: Fraud and Abuse; Revised PRO Sanctions for Failing To Meet Statutory Obligations, [Federal Register: April 29, 1997 (Volume 62, Number 82)] [Rules and Regulations] [Page 23140-23144]. This final rule addresses revised procedures governing the imposition and adjudication of program sanctions, based on recommendations from State utilization and quality control peer review organizations (PROs), resulting from enactment of sections 214 and 231(f) of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
• Privacy Act of 1974; Altered System of Records [National Practitioner Data Bank], [Federal Register: March 17, 1997 (Volume 62, Number 51)] [Notices] [Page 12653-12656]. A proposal to add a new category of records to the National Practitioner Data Bank for Adverse Information on Physicians and Other Health Care Practitioners. HRSA proposes to add specific information on physicians, practitioners, providers, and other health care entities which the Office of Inspector General (OIG), HHS has excluded from participation in and from recovering payment from the Medicare and Medicaid programs.
• 32 CFR Sec. 199.15 Peer Review Organization Program.
• 42 CFR PART 455 - PROGRAM INTEGRITY: MEDICAID
  • Sec. 455.1 Basis and scope.
  • Sec. 455.2 Definitions
  • Sec. 455.3 Other applicable regulations
  • Sec. 455.12 State plan requirement
  • Sec. 455.13 Methods for identification, investigation, and referral
  • Sec. 455.14 Preliminary investigation
  • Sec. 455.16 Resolution of full investigation
  • Sec. 455.17 Reporting requirements
  • Sec. 455.18 Provider's statements on claims forms
  • Sec. 455.19 Provider's statement on check
  • Sec. 455.20 Recipient verification procedure
  • Sec. 455.21 Cooperation with State Medicaid fraud control units
  • Sec. 455.23 Withholding of payments in cases of fraud
  • Sec. 455.100 Purpose
  • Sec. 455.101 Definitions
  • Sec. 455.102 Determination of ownership or control percentages
  • Sec. 455.103 State plan requirement
  • Sec. 455.104 Information on ownership and control
  • Sec. 455.105 Information related to business transactions
  • Sec. 455.106 Information on persons convicted of crimes
• 42 CFR PART 456 - UTILIZATION CONTROL
  • Sec. 456.1 Basis and purpose of part
  • Sec. 456.2 State plan requirements
  • Sec. 456.3 Statewide surveillance and utilization control program
  • Sec. 456.4 Responsibility for monitoring the utilization control program
  • Sec. 456.5 Evaluation criteria
  • Sec. 456.6 Review by State medical agency
  • Sec. 456.21 UR: Scope
  • Sec. 456.22 UR: Sample basis evaluation of services
  • Sec. 456.23 UR: Post-payment review process
  • Sec. 456.50 Hospital UR: Scope
  • Sec. 456.51 Hospital UR: Definitions
  • Sec. 456.150 Mental Hospital UR: Scope
  • Sec. 456.151 Mental Hospital UR: Definitions
  • Sec. 456.250 SNF UR: Scope
  • Sec. 456.251 SNF UR: Definitions
  • Sec. 456.350 ICF UR: Scope
  • Sec. 456.351 ICF UR: Definition
  • Sec. 456.480 Minor's Psych Services: Scope
  • Sec. 456.500 FFP, Waivers & Variances: Purpose
  • Sec. 456.501 UR plans as a condition for FFP
  • Sec. 456.523 Revised UR plan
  • Sec. 456.600 NH/ICF/IMD Inspections: Purpose
  • Sec. 456.601 NH/ICF/IMD Inspections: Definitions
  • Sec. 456.602 NH/ICF/IMD Inspections: Inspection team
  • Sec. 456.606 NH/ICF/IMD Inspections: Frequency of inspections
  • Sec. 456.607 NH/ICF/IMD Inspections: Notification before inspection
  • Sec. 456.608 NH/ICF/IMD Inspections: Personal contact with recipients
  • Sec. 456.609 NH/ICF/IMD Inspections: Determinations by team
  • Sec. 456.610 NH/ICF/IMD Inspections: Basis for determinations
  • Sec. 456.611 NH/ICF/IMD Inspections: Reports on inspections
  • Sec. 456.650 Penalties: Basis, purpose and scope
  • Sec. 456.651 Penalties: Definitions
  • Sec. 456.652 Penalties: Requirements for an effective utilization control program
  • Sec. 456.653 Penalties: Acceptable reasons for not meeting requirements
  • Sec. 456.654 Penalties: Requirements for content of showings
  • Sec. 456.655 Penalties: Validation of showings
  • Sec. 456.656 Penalties: Reductions in FFP
  • Sec. 456.657 Penalties: Computation of reductions in FFP
• 42 CFR PART 462 - PEER REVIEW ORGANIZATIONS
  • Sec. 462.1 Definitions
  • Sec. 462.100 Scope and applicability
  • Sec. 462.101 Eligibility requirements for PRO contracts
  • Sec. 462.102 Eligibility of physician-sponsored organizations
  • Sec. 462.103 Eligibility of physician-access organizations
  • Sec. 462.104 Requirements for demonstrating ability to perform review
  • Sec. 462.105 Prohibition against contracting with health care facilities
  • Sec. 462.106 Prohibition against contracting with payor organizations
  • Sec. 462.107 PRO contract award
• 42 CFR PART 466 - UTILIZATION AND QUALITY CONTROL REVIEW
  • 42 CFR Sec. 466.1 Definitions.
  • 42 CFR Sec. 466.70 Statutory bases and applicability.
  • 42 CFR Sec. 466.71 PRO review requirements.
  • 42 CFR Sec. 466.72 Review of the quality of care of risk-basis health
  • 42 CFR Sec. 466.73 Notification of PRO designation and implementation
  • 42 CFR Sec. 466.74 General requirements for the assumption of review.
  • 42 CFR Sec. 466.76 Cooperation with health care facilities.
  • 42 CFR Sec. 466.78 Responsibilities of health care facilities.
  • 42 CFR Sec. 466.80 Coordination with Medicare fiscal intermediaries
  • 42 CFR Sec. 466.82 Continuation of functions not assumed by PROs
  • 42 CFR Sec. 466.83 Initial denial determinations.
  • 42 CFR Sec. 466.84 Changes as a result of DRG validation.
  • 42 CFR Sec. 466.85 Conclusive effect of PRO initial denial determinations
  • 42 CFR Sec. 466.86 Correlation of Title XI functions with Title XVIII
  • 42 CFR Sec. 466.88 Examination of the operations and records
  • 42 CFR Sec. 466.90 Lack of cooperation by a health care facility
  • 42 CFR Sec. 466.93 Opportunity to discuss proposed initial denial
  • 42 CFR Sec. 466.94 Notice of PRO initial denial determination and changes
  • 42 CFR Sec. 466.96 Review period and reopening of initial denial
  • 42 CFR Sec. 466.98 Reviewer qualifications and participation.
  • 42 CFR Sec. 466.100 Use of norms and criteria.
  • 42 CFR Sec. 466.102 Involvement of health care practitioners
  • 42 CFR Sec. 466.104 Coordination of activities.
• 42 CFR PART 473 - RECONSIDERATIONS AND APPEALS (selected provisions follow).
  • 42 CFR Sec. 473.10 Scope.
  • 42 CFR Sec. 473.12 Statutory basis.
  • 42 CFR Sec. 473.14 Applicability.
  • 42 CFR Sec. 473.15 PRO review of changes resulting from DRG validation.
  • 42 CFR Sec. 473.16 Right to reconsideration.
  • 42 CFR Sec. 473.18 Location for submitting requests for reconsideration.
  • 42 CFR Sec. 473.20 Time limits for requesting reconsideration.
  • 42 CFR Sec. 473.22 Good cause for late filing of a request
  • 42 CFR Sec. 473.24 Opportunity for a party to obtain and submit
  • 42 CFR Sec. 473.26 Delegation of the reconsideration function.
  • 42 CFR Sec. 473.28 Qualifications of a reconsideration reviewer.
  • 42 CFR Sec. 473.30 Evidence to be considered by the reconsideration
  • 42 CFR Sec. 473.32 Time limits for issuance of the reconsidered
  • 42 CFR Sec. 473.36 Record of reconsideration.
  • 42 CFR Sec. 473.38 Finality of a reconsidered determination
  • 42 CFR Sec. 473.40 Beneficiary's right to a hearing.
  • 42 CFR Sec. 473.42 Submitting a request for a hearing.
  • 42 CFR Sec. 473.44 Determining the amount in controversy for a hearing.
  • 42 CFR Sec. 473.46 Appeals Council and judicial review.
  • 42 CFR Sec. 473.48 Reopening and revision of a reconsidered determination
• 42 CFR PART 476 - ACQUISITION, PROTECTION, AND DISCLOSURE OF PEER REVIEW INFORMATION
  • 42 CFR Sec. 476.101 Scope and definitions.
  • 42 CFR Sec. 476.102 Statutory bases for acquisition and maintenance of
  • 42 CFR Sec. 476.103 Statutory bases for disclosure of information.
  • 42 CFR Sec. 476.104 Procedures for disclosure by a PRO.
  • 42 CFR Sec. 476.105 Notice of disclosures made by a PRO
  • 42 CFR Sec. 476.106 Exceptions to PRO notice requirements.
  • 42 CFR Sec. 476.107 Limitations on redisclosure.
  • 42 CFR Sec. 476.108 Penalties for unauthorized disclosure.
  • 42 CFR Sec. 476.109 Applicability of other statutes and regulations.
  • 42 CFR Sec. 476.111 PRO access to records and information of institutions
  • 42 CFR Sec. 476.112 PRO access to records and information
  • 42 CFR Sec. 476.113 PRO access to information collected for PRO purposes.
  • 42 CFR Sec. 476.114 Limitation on data collection.
  • 42 CFR Sec. 476.115 Requirements for maintaining confidentiality.
  • 42 CFR Sec. 476.116 Notice to individuals and institutions under review.
  • 42 CFR Sec. 476.120 Information subject to disclosure.
  • 42 CFR Sec. 476.121 Optional disclosure of nonconfidential information.
  • 42 CFR Sec. 476.130 Disclosure to the Department.
  • 42 CFR Sec. 476.131 Access to medical records for the monitoring of PROs.
  • 42 CFR Sec. 476.132 Disclosure of information about patients.
  • 42 CFR Sec. 476.133 Disclosure of information about practitioners,
  • 42 CFR Sec. 476.134 Verification and amendment of PRO information.
  • 42 CFR Sec. 476.135 Disclosure necessary to perform review
  • 42 CFR Sec. 476.136 Disclosure to intermediaries and carriers.
  • 42 CFR Sec. 476.137 Disclosure to Federal and State enforcement agencies
  • 42 CFR Sec. 476.138 Disclosure for other specified purposes.
  • 42 CFR Sec. 476.139 Disclosure of PRO deliberations and decisions.
  • 42 CFR Sec. 476.140 Disclosure of quality review study information.
  • 42 CFR Sec. 476.141 Disclosure of PRO interpretations
  • 42 CFR Sec. 476.142 Disclosure of sanction reports.
  • 42 CFR Sec. 476.143 PRO involvement in shared health data systems
• 45 CFR PART 60 - NATIONAL PRACTITIONER DATA BANK
  • 45 CFR Sec. 60.1 The National Practitioner Data Bank.
  • 45 CFR Sec. 60.2 Applicability of these regulations.
  • 45 CFR Sec. 60.3 Definitions.
  • 45 CFR Sec. 60.4 How information must be reported.
  • 45 CFR Sec. 60.5 When information must be reported.
  • 45 CFR Sec. 60.6 Reporting errors, omissions, and revisions.
  • 45 CFR Sec. 60.7 Reporting medical malpractice payments.
  • 45 CFR Sec. 60.8 Reporting licensure actions taken by Boards of Medical Examiners.
  • 45 CFR Sec. 60.9 Reporting adverse actions on clinical privileges.
  • 45 CFR Sec. 60.10 Information which hospitals must request
  • 45 CFR Sec. 60.11 Requesting information from the National Practitioner Data Bank .
  • 45 CFR Sec. 60.12 Fees applicable to requests for information.
  • 45 CFR Sec. 60.13 Confidentiality of National Practitioner Data Bank information.
  • 45 CFR Sec. 60.14 How to dispute the accuracy of information.

• Long-Term Care: Consumer Protection and Quality-of-Care Issues in Assisted Living (Letter Report, 05/15/97, GAO/HEHS-97-93). Pursuant to congressional request, GAO reviewed assisted living facilities (ALF), focusing on: (1) responsibilities of federal and state governments and ALFs in ensuring quality and protecting consumers living in ALFs; and (2) issues that may require further research.
• Medical Malpractice: Federal Tort Claims Act Coverage Could Reduce Health Centers' Costs (Letter Report, 04/14/97, GAO/HEHS-97-57). Pursuant to a legislative requirement, GAO reviewed the implementation of Federal Tort Claims Act (FTCA) coverage for community health centers.
• Medicare: Private-Sector and Federal Efforts to Assess Health Care Quality (Testimony, 09/19/96, GAO/T-HEHS-96-215). GAO discussed the Health Care Financing Administration's (HCFA) efforts to provide health care quality information to Medicare beneficiaries joining health maintenance organizations.
• Practice Guidelines: Managed Care Plans Customize Guidelines to Meet Local Interests (Letter Report, 05/30/96, GAO/HEHS-96-95). Pursuant to a congressional request, GAO reviewed how managed health plans make use of existing clinical practice guidelines.
• Medicare: Federal Efforts to Enhance Patient Quality of Care (Chapter Report, 04/10/96, GAO/HEHS-96-20). Pursuant to a congressional request, GAO reviewed the Health Care Financing Administration's (HCFA) efforts to enhance the quality of care for Medicare beneficiaries.
• Medicare: Millions Can Be Saved by Screening Claims for Overused Services (Letter Report, 01/30/96, GAO/HEHS-96-49). GAO provided information on Medicare payments for unnecessary medical services.
• Medical Liability: Impact on Hospital and Physician Costs Extends Beyond Insurance (Letter Report, 09/29/95, GAO/AIMD-95-169). As Congress considers proposals to reduce to tort liability in the health care industry, little consensus exists on the extent to which medical liability-related spending boosts hospital and physician expenditures, a central issue in the debate over health care reform.
• Practice Guidelines: Overview of Agency for Health Care Policy and Research Efforts (Testimony, 07/25/95, GAO/T-HEHS-95-221). In 1989, Congress created the Agency for Health Care Policy and Research--part of the Public Health Service--to serve as the federal government's focal point for effectiveness and outcomes research.
• Long-Term Care: Status of Quality Assurance and Measurement in Home and Community-Based Services (Letter Report, 03/31/94, GAO/PEMD-94-19). This report examines how quality is ensured and measured in home and community-based long-term care services for elderly persons with disabilities.
• Medical Malpractice: Maine's Use of Practice Guidelines to Reduce Costs (Letter Report, 10/25/93, GAO/HRD-94-8). As part of a larger goal of reducing health care costs and improving medical care, Maine is testing an innovative medical malpractice reform initiative.

• AMSO Ethics of Managed Care Interesting forum on the ethics of managed care.
• AMSO Managed Healthcare Forum AMSO provides the provider community with management services that facilitate the health care professionals role and sophistication in the managed health care marketplace.
• Andrews Fosmire - Physician's Guide to Medical Liability Litigation This Guide is intended as a reference for physicians practicing in the State of Michigan. Some of the information it provides is Michigan-specific and does not apply in other States.
• Almighty Source of Healing It was a bright and shiny morning outside when the bright and bushy-tailed staff learned the great news. Certain aspects of our wonderful hospital were not up to snuff for the JCAHO Masters.
• Electronic Medical Records: Security and Confidentiality Issues Professionals using electronic medical records will have some understanding of the legal implications and requirements on these systems. (Lists JCAHO requirements).
• HSR: Impact of Varying Panel Membership on Ratings of Appropriateness in Consensus Panels: A Comparison of a Multi- and Single Disciplinary Panel The objective of the study was to examine the appropriateness ratings for the use of spinal manipulation for low back pain of a multidisciplinary panel of medical and chiropractic physicians, and those of a panel composed only of chiropractic physicians.
• INTERGOVERNMENTAL HEALTH POLICY PROJECT For more than sixteen years, we have concentrated our research efforts solely on the health laws and programs of the fifty states.
• INFOSHP Home Page The Information for State Health Policy site is intended to help interested parties locate Model Reports and Standards for health statistical information, experience electronic Query submittal, and locate related health information resources.
• JCAHO Survey Questionnaire
• JCAHO Home Page The Joint Commission evaluates and accredits more than 15,000 health care organizations in the United States, including more than 5,200 hospitals and nearly 10,000 other health care organizations.
• JCAHO Press Releases The latest from the JCAHO!
• NCQA The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans, including health maintenance organizations (HMOs).
• NCQA Accreditation NCQA accreditation evaluates how well a health plan manages all parts of its delivery system --- physicians, hospitals, other providers, and administrative services --- in order to continuously improve health care for its members.
• NCQA NEWS The latest from NCQA!
• NATIONAL ASSOCIATION OF HEALTH DATA ORGANIZATIONS HOME PAGE The National Association of Health Data Organizations (NAHDO) is the premier health information organization dedicated to improving health care through the collection, analysis, dissemination, and use of health care data.
• RAND: Malpractice Claims Data as a Quality Improvement Tool This Note attempts to identify potentially preventable sources of medical injury in obstetrics and gynecology, general surgery, anesthesiology, and radiology.
• RAND: Malpractice Claims Data as a Quality Improvement Tool: II. This Note attempts to evaluate the usefulness of malpractice claims data for identifying (1) physicians who are prone to negligent errors and (2) physician and hospital characteristics associated with particular kinds of errors.

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