[Code of Federal Regulations]
[Title 42, Volume 3]
[Revised as of October 1, 2004]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR480.133]

[Page 474-475]
 
                         TITLE 42--PUBLIC HEALTH
 
  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 
                  HEALTH AND HUMAN SERVICES (CONTINUED)
 
PART 480_ACQUISITION, PROTECTION, AND DISCLOSURE QUALITY IMPROVEMENT 
ORGANIZATION INFORMATION--Table of Contents
 
     Subpart B_Utilization and Quality Control Quality Improvement 
                          Organizations (QIOs)
 
Sec. 480.133  Disclosure of information about practitioners, reviewers and 
institutions.

    (a) General requirements for disclosure. Except as specified in 
paragraph (b) of this section, the following provisions are required of 
the QIO.
    (1) Disclosure to the identified individual or institution. A QIO 
must disclose, to particular practitioners, reviewers and institutions, 
information about themselves, upon request, and may disclose it to them 
without a request.
    (2) Disclosure to others. (i) A QIO must disclose to an institution, 
upon request, information on a practitioner to the extent that the 
information displays practice or performance patterns of the 
practitioner in that institution.
    (ii) In accordance with section 1160 of the Act, a QIO must disclose 
information that displays practice or performance patterns of a 
practitioner or institution in accordance with the procedures for 
disclosures specified in Sec. Sec. 480.137 and 480.138 to--
    (A) Federal and State agencies that are responsible for the 
investigation of fraud and abuse of the Medicare or Medicaid programs, 
and
    (B) Federal and State agencies that are responsible for licensing 
and certification of practitioners and providers.
    (iii) A QIO may disclose to any person, agency, or organization 
information on a particular practitioner or reviewer at the written 
request of or with the written consent of that practitioner or reviewer. 
The recipient of the information has the same redisclosure rights and 
responsibilities as the requesting or consenting practitioner or 
reviewer as provided under this Subpart B.
    (b) Exceptions. (1) If the request is in connection with an initial 
denial determination or a change resulting from a diagnostic related 
group (DRG) coding validation under Part 466 of this subchapter, the QIO 
must provide only the

[[Page 475]]

information used to support that determination in accordance with the 
procedures for disclosure of information relating to determinations 
under Sec. 473.24.
    (2) A QIO must disclose information regarding QIO deliberations only 
as specified in Sec. 480.139(a).
    (3) A QIO must disclose quality review study information only as 
specified in Sec. 480.140.

[50 FR 15359, Apr. 17, 1885, as amended at 52 FR 37458, Oct. 7, 1987; 52 
FR 47004, Dec. 11, 1987. Redesignated at 64 FR 66279, Nov. 24, 1999, as 
amended at 69 FR 49266, 29267, Aug. 11, 2004]