Appropriate Use Criteria Program - Provider Led Entities
Guidance for explaining what PLEs are, how one's organization becomes a PLE and a current list of PLEs.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: August 10, 2020
NOTICE: As announced in the CY 2024 Physician Fee Schedule (PFS) Final Rule, effective January 1, 2024, CMS is pausing efforts to implement the AUC program for reevaluation and rescinding the AUC regulations at 42 CFR 414.94, reserving this section for future use. CMS has not specified a timeframe within which implementation efforts will recommence. See pages 79256-79265 of the final rule.
Effective January 1, 2024, providers and suppliers should no longer include AUC consultation information on Medicare FFS claims. Additionally, CMS will no longer qualify PLEs or CDSMs and will remove this information from the AUC website. The claims processing instructions and guidance for the educational and operations testing period will also be removed.
Background
A Provider-led entity (PLE) is a national professional medical specialty society or other organization that is comprised primarily of providers or practitioners who, either within the organization or outside of the organization, predominantly provide direct patient care. Once a PLE is qualified, the appropriate use criteria (AUC) developed, modified or endorsed by the entity are considered specified applicable AUC.
PLEs Seeking Qualification
- Applications must document current adherence to the evidence-based processes described in 42 CFR 414.94(c)(1) when developing or modifying AUC and describe how the entity meets the definition of PLE described in 42 CFR 414.94(b).
- CMS has not provided an application template.
- Send applications to ImagingAUC@cms.hhs.gov by January 1
We will post qualified PLEs to our website. All qualified PLEs must re-apply every five years and applications must be received by January 1 during the fifth year of their approval.
Qualified PLEs as of May 2023
American College of Cardiology Foundation
American College of Radiology
The CDI Quality Institute doing business as (d/b/a) The RAYUS Quality Institute
Duke University Health System*
High Value Practice Academic Alliance
Intermountain Healthcare
Johns Hopkins University School of Medicine
Memorial Sloan Kettering Cancer Center
National Comprehensive Cancer Network
Society for Nuclear Medicine and Molecular Imaging
University of California Medical Campuses
University of Pennsylvania Health System
University of Texas MD Anderson Cancer Center
University of Utah Health
University of Washington School of Medicine
Weill Cornell Medicine Physicians Organization
* Indicates newly qualified PLEs as of June 30, 2022
Information Collections Under 42 CFR 414.94
OMB Control Number: 0938-1288
Expiration Date: 6/30/2019
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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.