[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

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

[CITE: 42CFR476.71]



[Page 466-467]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 476_UTILIZATION AND QUALITY CONTROL REVIEW--Table of Contents

 

  Subpart C_Review Responsibilities of Utilization and Quality Control 

                Quality Improvement Organizations (QIOs)

 

Sec.  476.71  QIO review requirements.



    (a) Scope of QIO review. In its review, the QIO must determine (in 

accordance with the terms of its contract)--

    (1) Whether the services are or were reasonable and medically 

necessary for the diagnosis and treatment of illness or injury or to 

improve functioning of a malformed body member, or (with respect to 

pneumococcal vaccine) for prevention of illness or (in the case of 

hospice care) for the palliation and management of terminal illness;

    (2) Whether the quality of the services meets professionally 

recognized standards of health care;



[[Page 467]]



    (3) Whether those services furnished or proposed to be furnished on 

an inpatient basis could, consistent with the provisions of appropriate 

medical care, be effectively furnished more economically on an 

outpatient basis or in an inpatient health care facility of a different 

type;

    (4) Through DRG validation, the validity of diagnostic and 

procedural information supplied by the hospital;

    (5) The completeness, adequacy and quality of hospital care 

provided;

    (6) The medical necessity, reasonableness and appropriateness of 

hospital admissions and discharges;

    (7) 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; and

    (8) Whether a hospital has misrepresented admission or discharge 

information or has taken an action that results in--

    (i) The unnecessary admission of an individual entitled to benefits 

under part A;

    (ii) Unnecessary multiple admissions of an individual; or

    (iii) Other inappropriate medical or other practices with respect to 

beneficiaries or billing for services furnished to beneficiaries.

    (b) Payment determinations. On the basis of the review specified 

under paragraphs (a) (1), (3), (6), (7), and (8) of this section, the 

QIO must determine whether payment may be made for these services. A QIO 

may grant a period of not more than two days (grace days) for the 

purpose of arranging post discharge care when the provider did not know 

or could not reasonably be expected to have known that payment for the 

service(s) would not be made under the Medicare program as specified in 

Sec.  405.330(b).

    (c) Other duties and functions. (1) The QIO must review at least a 

random sample of hospital discharges each quarter and submit new 

diagnostic and procedural information to the Medicare fiscal 

intermediary or carrier if it determines that the information submitted 

by the hospital was incorrect.

    (2) As directed by CMS, the QIO must review changes in DRG and LTC-

DRG assignments made by the intermediary under the provisions of 

Sec. Sec.  412.60(d) and 412.513(c) of this chapter that result in the 

assignment of a higher-weighted DRG or a different LTC-DRG. The QIO's 

review must verify that the diagnostic and procedural information 

supplied by the hospital is substantiated by the information in the 

medical record.

    (d) Coordination of sanction activities. The QIO must carry out the 

responsibilities specified in subpart C of part 1004 of this title 

regarding imposition of sanctions on providers and practitioners who 

violate their statutory obligations under section 1156 of the Act.



[52 FR 37457, Oct. 7, 1987; 52 FR 47003, Dec. 11, 1987, as amended at 59 

FR 45402, Sept. 1, 1994. Redesignated at 64 FR 66279, Nov. 24, 1999; 67 

FR 56056, Aug. 30, 2002]