[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR412.44]



[Page 479]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 412_PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES

--Table of Contents

 

 Subpart C_Conditions for Payment Under the Prospective Payment Systems 

    for Inpatient Operating Costs and Inpatient Capital-Related Costs

 

Sec. 412.44  Medical review requirements: Admissions and quality review.



    Beginning on November 15, 1984, a hospital must have an agreement 

with a QIO to have the QIO review, on an ongoing basis, the following:

    (a) The medical necessity, reasonableness and appropriateness of 

hospital admissions and discharges.

    (b) The medical necessity, reasonableness and appropriateness of 

inpatient hospital care for which additional payment is sought under the 

outlier provisions of Sec. Sec. 412.82 and 412.84 of this chapter.

    (c) The validity of the hospital's diagnostic and procedural 

information.

    (d) The completeness, adequacy, and quality of the services 

furnished in the hospital.

    (e) Other medical or other practices with respect to beneficiaries 

or billing for services furnished to beneficiaries.



[50 FR 15326, Apr. 17, 1985, as amended at 50 FR 35689, Sept. 3, 1985; 

50 FR 41886, Oct. 16, 1985]