Medicaid Program; External Quality Review of Medicaid Managed Care Organizations
medicare · Centers for Medicare and Medicaid Services · Rule · Published 2003-01-24 · Effective 2003-03-25 · 68 FR 3586
Document
Document number
03-1294
Federal Register citation
68 FR 3586
CFR reference
42 CFR 433
Type
Rule
Action
Final rule.
Category
medicare
Sub-agency
Centers for Medicare and Medicaid Services
Publication date
2003-01-24
Effective date
2003-03-25
HHS docket
CMS-2015-F
Abstract
This final rule establishes requirements and procedures for external quality review (EQR) of Medicaid managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs). It defines who qualifies to conduct EQR and what activities can be conducted as part of EQR. In addition, under certain circumstances, this rule allows State agencies to (1) use findings from particular Medicare or private accreditation review activities to avoid duplicating review activities, or (2) exempt certain Medicare MCOs and PIHPs from all EQR requirements. Also, this rule allows the payment of enhanced Federal financial participation (FFP) at the 75 percent rate for the administrative costs of EQRs or EQR activities that are conducted by approved entities.