CMS-10294.Appendix A (8-23-10)

APPENDIX A
LEGISLATION FOR THE NINTH SCOPE OF WORK QUALITY IMPROVEMENT
PROGRAM EVALUATION

RELEVANT LEGISLATION FROM THE SOCIAL SECURITY ACT

Section 1154(a)(8). The organization shall perform such duties and functions and assume such
responsibilities and comply with such other requirements as may be required by this part or
under regulations of the Secretary promulgated to carry out the provisions of this part or as may
be required to carry out section 1862(a)(15).
Section 1154(a)(10). The organization shall coordinate activities, including information
exchanges, which are consistent with economical and efficient operation of programs among
appropriate public and private agencies or organizations including—
(A) agencies under contract pursuant to sections 1816 and 1842 of this Act;
(B) other peer review organizations having contracts under this part; and
(C) other public or private review organizations as may be appropriate.
Section 1156(a). It shall be the obligation of any health care practitioner and any other person
(including a hospital or other health care facility, organization, or agency) who provides health
care services for which payment may be made (in whole or in part) under this Act, to assure, to
the extent of his authority that services or items ordered or provided by such practitioner or
person to beneficiaries and recipients under this Act—
(1) will be provided economically and only when, and to the extent, medically necessary;
(2) will be of a quality which meets professionally recognized standards of health care; and
(3) will be supported by evidence of medical necessity and quality in such form and fashion and
at such time as may reasonably be required by a reviewing peer review organization in the
exercise of its duties and responsibilities.
Section 1156(c). It shall be the duty of each utilization and quality control peer review
organization to use such authority or influence it may possess as a professional organization, and
to enlist the support of any other professional or governmental organization having influence or
authority over health care practitioners and any other person (including a hospital or other health
care facility, organization, or agency) providing health care services in the area served by such
review organization, in assuring that each practitioner or person (referred to in subsection (a))
providing health care services in such area shall comply with all obligations imposed on him
under subsection (a).
Section 1862(g). The Secretary shall, in making the determinations under paragraphs (1) and (9)
of subsection (a), and for the purposes of promoting the effective, efficient, and economical
delivery of health care services, and of promoting the quality of services of the type for which
payment may be made under this title, enter into contracts with utilization and quality control
peer review organizations pursuant to part B of title XI of this Act.

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