DELAWARE AND KANSAS PEER REVIEW ORGANIZATION The Health Care Financing Administration (HCFA) plans to issue a Request for Proposal (RFP) to designate an organization as a Peer Review Organization (PRO) for the State of Delaware and Kansas and will be competitively awarded and the award of this contract will be on or about April 1, 1999. In order to be eligible to recieve a PRO contract, an offeror must meet the definition of a "utilization and quality control peer review organization" as set forth in Section 1152 of the Social Security Act (the Act). PROs are responsible for the review of certain health care services furnished under Title XVII of the Act and under certain other Federal programs to determine whether those services are reasonable, medically necessarey, furnished in the appropriate setting and are of a quality which meets professionally recognized standards. PRO activities are part of the Health Care Quality Improvement Program (HCQIP), a program which supports the mission of HCFA to assure health care security for eligible beneficiaries. The HCQIP is carried out locally by the PRO in each state. The HCQIP rests in the belief that a provider's or practioners internal quality management system is the key to good health care plan performance. Under the HCQIP, PROs provide medical reviews to health care plans, providers, and practitioners to improve the quality of care furnished to Medicare beneficiaries. The organizations that are eligible to contract as PROs have satisfactorily demonstrated that they are either physician-sponsored or physician-access organizations in accordance with Sections 1152 and 1153 of the Act and our regulations at 42 CFR 462.102 AND 462.103. In addition, the organization must not be a health care facility, health care facility association, or a health care facility affiliate, and must have a consumer representative on its governing board. A physician-sponsored organization is one that is both composed of a least 10 percent of the licensed doctors of medicine or osteopathy practicing medicine or surgery in the respective review are and is representative of the physicians practicing in the review area. The representation requirement can be met if the organization has documentation in its files demonstrating that it is composed of a least 20 percent of the licensed doctors of medicine and osteopathy practicing medicine or surgery in the review area; or if the organization demonstrates, through letters of support from physicians or through other means, that it is representative of the area physicians. A physician-access organization is one that has available to it by arrangement or otherwise, the services of a sufficient number of licensed doctors of medicine or osteopathy practicing medicine or surgery in the review area to assure adequate peer review of the services furnished by the various medical specialities or subspecialities. The organization meets this requirement if it has an arrangement or arrangements with physicians under which the physicians would conduct review for the organization. In addition, PROs are responsible for certain other activities necessary or incident to the performance of the contract. All requirements will be included in the RFP. The definition, contract requirements, functions and duties of PROs are generally defined by Titles XI and XVIII of the Social Security Act. A future CBD notice will advise when the RFP for the PRO for the State of Delaware and Kansas will be available.

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