[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: 42CFR476.74]



[Page 468]

 

                         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.  476.74  General requirements for the assumption of review.



    (a) A QIO must assume review responsibility in accordance with the 

schedule, functions and negotiated objectives specified in its contract 

with CMS.

    (b) A QIO must notify the appropriate Medicare fiscal intermediary 

or carrier of its assumption of review in specific health care 

facilities no later than five working days after the day that review is 

assumed in the facility.

    (c) A QIO must maintain and make available for public inspection at 

its principal business office--

    (1) A copy of each agreement with Medicare fiscal intermediaries and 

carriers;

    (2) A copy of its currently approved review plan that includes the 

QIO's method for implementing review; and

    (3) Copies of all subcontracts for the conduct of review.

    (d) A QIO must not subcontract with a facility to conduct any review 

activities except for the review of the quality of care. The QIO may 

subcontract with a non-facility organization to conduct review in a 

facility.

    (e) If required by CMS, a QIO is responsible for compiling 

statistics based on the criteria contained in Sec.  405.332 of this 

chapter and making limitation of liability determinations on excluded 

coverage of certain services that are made under section 1879 of the 

Act. If required by CMS, QIOs must also notify a provider of these 

determinations. These determinations and further appeals are governed by 

the reconsideration and appeals procedures in part 405, subpart G of 

this chapter for Medicare Part A related determinations and part 405, 

subpart H of this chapter for Medicare Part B related determinations.

    (f) A QIO must make its responsibilities under its contract with 

CMS, primary to all other interests and activities that the QIO 

undertakes.