§405.925. Decisions of utilization review committees.
42 C.F.R. § 405.925
General rule. A decision of a utilization review committee is a medical determination by a staff committee of the provider or a group similarly composed and does not constitute a determination by the Secretary within the meaning of section 1869 of the Act. The decision of a utilization review committee may be considered by CMS along with other pertinent medical evidence in determining whether or not an individual has the right to have payment made under Part A of title XVIII.
Applicability under the prospective payment system. CMS may consider utilization review committee decisions related to inpatient hospital services paid for under the prospective payment system (see part 412 of this chapter) only as those decisions concern:
The appropriateness of admissions resulting in payments under subparts D, E and G of part 412 of this chapter.
The covered days of care involved in determinations of outlier payments under § 412.80(a)(1)(i) of this chapter; and
The necessity of professional services furnished in high cost outliers under § 412.80(a)(1)(ii) of this chapter.
Notes, amendments, and revision history
Amendments
[48 FR 39831, Sept. 1, 1983. Redesignated at 77 FR 29028, May 16, 2012]
Source
Source: 70 FR 11472, Mar. 8, 2005, unless otherwise noted.
Authority
Authority: 42 U.S.C. 263a, 405(a), 1302, 1320b-12, 1395x, 1395y(a), 1395ff, 1395hh, 1395kk, 1395rr, and 1395ww(k).
Amendments
[48 FR 39831, Sept. 1, 1983. Redesignated at 77 FR 29028, May 16, 2012]