Title 32 National Defense Civilian Health And Medical Program Of The Uniformed Services (CHAMPUS) Part 199.15 Quality And Utilization Review Peer Review Organization Program Revision: Rule: (a) General. (1) Purpose. (2) Applicability of program. (3) Contractor implementation. (4) Medical issues affected. (5) Provider responsibilities. (6) Medicare rules used as model. (b) Objectives and general requirements of review system-- (1) In general. (2) Payment exclusion for services provided contrary to utilization and quality standards. (3) Review of services covered by DRG-based payment system. (4) Preauthorization and other utilization review procedures-- (i) In general. (ii) Preauthorization procedures. (iii) Payment reduction for noncompliance with required utilization review procedures. (c) Hospital cooperation. (d) Areas of review-- (1) Admissions. (2) DRG validation. (3) Outlier review. (4) Procedure review. (5) Other review. (e) Actions as a result of review-- (1) Findings related to individual claims. (2) Findings related to a pattern of inappropriate practices. (3) Revision of coding relating to DRG validation. (f) Special procedures in connection with certain types of health care services or certain types of review activities-- (1) In general. (2) Services not covered by the DRG-based payment system. (3) Peer review activities by contractors also performing other administration or management functions-- (i) Sole-function PRO versus multi-function PRO. (ii) Special rules and procedures. (g) Procedures regarding initial determinations. (h) Procedures regarding reconsiderations. (i) Appeals and hearings. (j) Acquisition, protection and disclosure of peer review information. (k) Limited immunity from liability for participants in PRO program. (l) Additional provision regarding confidentiality of records-- (1) General rule. (2) Specific applications. (m) Obligations, sanctions and procedures. (n) Authority to integrate CHAMPUS PRO and military medical treatment facility utilization review activities.