Background and Responsibilities of the Peer Review Organization (PRO)

60 - Background and Responsibilities of the Peer Review Organization (PRO) (Rev. 1, 09-11-02) Section 1153 of the Social Security Act (the Act) requires the Secretary to enter into contracts with physician-approved or physician-access organizations defined as PROs. The PROs are organizations who are responsible for monitoring the quality of care provided to Medicare patients by hospitals, SNFs, home health agencies, Medicare+Choice plans, and other types of health care providers. PRO review is governed by titles XI and XVIII of the Act as amended, and by regulations contained in: • 42 CFR 411 - Limitation on liability; • 42 CFR 412 - Outlier review, diagnosis related group (DRG) validation, and hospital notices of non coverage; • 42 CFR 417.605 - Immediate PRO review of Health Maintenance Organization (HMO)/Competitive Medical Plan (CMP) notices of discharge; • 42 CFR 422.622 - Immediate review of Medicare+Choice discharge notices; • 42 CFR 475 - Definition of eligible organizations and area designation; • 42 CFR 476 - Assumption and conduct of review; • 42 CFR 478 - PRO reconsideration and appeals; • 42 CFR 480 - Disclosure of information; • 42 CFR 482 - Hospital conditions of participation; and • 42 CFR 1004 - PRO recommendations of sanctions.