---
kind: "section"
citation: "42 C.F.R. § 476.100"
title: "42"
number: "476.100"
heading: "Use of norms and criteria."
url: "https://uscodex.org/cfr/42/476.100"
---

# §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.**

## Notes

### Source

Source: 50 FR 15330, Apr. 17, 1985, unless otherwise noted. Redesignated at 64 FR 66279, Nov. 24, 1999.

### Authority

Authority: 42 U.S.C. 1302 and 1395hh.

### Source

Source: 44 FR 32081, June 4, 1979, unless otherwise noted. Redesignated at 64 FR 66279, Nov. 24, 1999.