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Title: Section 708.4 - General review criteria

708.4 General review criteria. (a) The specific review criteria for specific services, as set forth in section 708.5 of this Part, relate to the need, accessibility and availability, financial viability, cost effectiveness and quality of the service as characteristics of appropriateness, and shall consider, where appropriate, the following general considerations:

(1) the relationship of the health service being reviewed to the applicable health systems plans, annual implementation plans, and State Health Plan;

(2) the relationship of the service being reviewed to the long-range development plan, if any, of the person or entity providing such service;

(3) the need that the population served has for the service, and the extent to which low-income persons, handicapped persons, and other underserved groups have access to such service;

(4) the availability of less costly or more effective alternative methods of providing the service being reviewed;

(5) the relationship of the service being reviewed to the existing health care system of the area in which such service is provided;

(6) the availability of resources, including health manpower, management personnel and funds for capital and operating costs, for the provision of the service being reviewed, and the availability of alternative uses of these resources for the provision of other health services.

(7) the special needs and circumstances of those persons or entitles which provide a substantial portion of their services or resources, or both, to individuals not residing in the health service areas in which such persons or entities are located, or in adjacent health services areas. These persons or entities may include medical and other health-profession schools, multidisciplinary clinics, and specialty centers;

(8) the special needs and circumstances of Health Maintenance Organizations (HMO's). In the case of areawide reviews which result in institution-specific findings regarding services provided by or through an HMO, the needs and circumstances shall be limited to:

(i) the needs of enrolled members and reasonably anticipated new members of the HMO for the existing institutional health services provided by the organization;

(ii) whether the services can be obtained from non-HMO, or other HMO, providers in a reasonable and cost-effective manner which is consistent with the basic method of operation of the HMO; and

(iii) any other factors which the commissioner may propose, consistent with the National Health Planning and Resources Development Act of 1974, Public Law 93 641, as amended;

(9) the special needs and circumstances of biomedical and behavioral research projects which are designed to meet a national need and for which local conditions offer special advantages;

(10) the contribution of the existing institutional health services in meeting the health-related needs of members of medically underserved groups and other groups which have traditionally experienced difficulties in obtaining equal access to health services--for example, low-income persons, racial and ethnic minorities, women and handicapped persons--particularly those needs identified in the applicable health systems plan and annual implementation plan as deserving of priority;

(11) the special circumstances of health service institutions with respect to the need for conserving energy;

(12) the effect of competition on the supply of the health services being reviewed;

(13) improvements or innovations in the financing and delivery of health services which foster competition and serve to promote quality assurance and cost effectiveness; and

(14) the quality of care provided by the services or facilities in the past.

(b) Specific review criteria may vary according to the type of service being reviewed, purpose of the review, and need not address all of the characteristics of appropriateness.


VOLUME D (Title 10)