Sec. 504. Elimination of utilization review programs; transition
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It is the intention of this title to replace by January 1, 2017, random utilization controls with a systematic review of patterns of practice that compromise the quality of care. Subject to the succeeding provisions of this subsection, the program of quality review provided under the previous sections of this title supersede all existing Federal requirements for utilization review programs, including requirements for random case-by-case reviews and programs requiring pre-certification of medical procedures on a case-by-case basis.
Before January 1, 2017, the Board and the States may employ existing utilization review standards and mechanisms as may be necessary to effect the transition to pattern of practice-based reviews. Nothing in this subsection shall be construed— as precluding the case-by-case review of the provision of care— in individual incidents where the quality of care has significantly deviated from acceptable standards of practice; and with respect to a provider who has been determined to be an outlier; or as precluding the case management of catastrophic, mental health, or substance abuse cases or long-term care where such management is necessary to achieve appropriate, cost-effective, and beneficial comprehensive medical care, as provided for in section 204.