Q--Peer Reviews to determine the medical necessityand appropriateness of mecial treatment, evaluatequality of care to determine if it providedexpected standard of care for type of case andsetting.

The purpose of the review will be to determine the medical necessity and appropriateness of medical treatment, to evaluate the quality of care, and to otherwise determine if the care provided to the patient met the expected standard of care for the type of case and the setting of the service. The contractor will have each case reviewed by a nurse screener. The nurse will be experienced in the review of medical records. The case will be referred to a board certified physician in active practice in the same or a similar specialty and in the type of case under review. The peer physician will examine the medical record, and will prepare a written summary of the case detailing any issues of concern noting areas that may need additional information. The case summary with comments and recommendations as appropriate is submitted to the administrator of the facility. Recommendations may include continuing education suggestions, protocals that are recommended and other improvements that will assist in patient care. The peer review form must be completed and if they find an area of care that is not up to standard based upon the elements of care identified on the form that they give a written explanation for their decision. The peer reviewer must fill in the identified level of care on the form. Level 1, level 2 or level 3. The peer review must be completed within 30 days.