[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: 42CFR476.86]



[Page 471-472]

 

                         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.  476.86  Correlation of Title XI functions with Title XVIII 



functions.



    (a) Payment determinations. (1) QIO initial denial determinations 

under this part with regard to the reasonableness, medical necessity, 

and appropriateness of placement at an acute level of patient care as 

are also conclusive for payment purposes with regard to the following 

medical issues:

    (i) Whether inpatient care furnished in a psychiatric hospital meets 

the requirements of Sec.  424.14 of this chapter.

    (ii) Whether payment for inpatient hospital or SNF care beyond 20 

consecutive days is precluded under Sec.  489.50 of this chapter because 

of failure to perform review of long-stay cases.

    (iii) Whether the care furnished was custodial care or care not 

reasonable and necessary and, as such, excluded under Sec.  405.310(g) 

or Sec.  405.310(k) of this chapter.

    (iv) Whether the care was appropriately furnished in the inpatient 

or outpatient setting.

    (2) Reviews with respect to determinations listed in paragraph 

(a)(1) of this section must not be conducted, for purposes of payment, 

by Medicare fiscal intermediaries or carriers except as outlined in 

paragraph (c) of this section.

    (3) QIOs make determinations as to the appropriateness of the 

location in which procedures are performed. A procedure may be medically 

necessary but denied if the QIO determines that it could, consistent 

with the provision of appropriate medical care, be effectively provided 

more economically on an outpatient basis or in an inpatient health care 

facility of a different type.

    (4) QIO determinations as to whether the provider and the 

beneficiary knew or could reasonably be expected to have known that the 

services described in paragraph (a)(1) of this section were excluded are 

also conclusive for payment purposes.

    (b) Utilization review activities. QIO review activities to 

determine whether inpatient hospital or SNF care services are reasonable 

and medically necessary and are furnished at the appropriate level of 

care fulfill the utilization review requirements set forth in Sec. Sec.  

405.1035, 405.1042, and 405.1137 of this chapter.

    (c) Coverage. Nothing in paragraphs (a) (1) and (3) of this section 

will be construed as precluding CMS or a Medicare fiscal intermediary or 

carrier, in the proper exercise of its duties and functions, from 

reviewing claims to determine:

    (1) In the case of items or services not reviewed by a QIO, whether 

they meet coverage requirements of Title XVIII relating to medical 

necessity, reasonableness, or appropriateness of placement at an acute 

level of patient care. However, if a coverage determination pertains to 

medical necessity, reasonableness, or appropriateness of placement at an 

acute level of patient care, the fiscal intermediary or carrier



[[Page 472]]



must use a QIO to make a determination on those issues if a QIO is 

conducting review in the area and must abide by the QIO's determination.

    (2) Whether any claim meets coverage requirements of Title XVIII 

relating to issues other than medical necessity, reasonableness or 

appropriateness of placement at an acute level of patient care.

    (d) Payment. Medicare fiscal intermediaries and carriers are not 

precluded from making payment determinations with regard to coverage 

determinations made under paragraph (c) of this section.

    (e) Survey, compliance and assistance activities. QIO review and 

monitoring activities fulfill the requirements for compliance and 

assistance activities of State survey agencies under section 1864(a) 

with respect to sections 1861(e)(6), 1861(j)(8), 1861(j)(12), and 

1861(k) of the Act, and activities required of intermediaries and 

carriers under Sec. Sec.  421.100(d) and 421.200(f) of this chapter.

    (f) Appeals. The requirements and procedures for QIO review of 

changes as a result of DRG validation and the reconsideration, hearing 

and judicial review of QIO initial denial determinations are set forth 

in part 473 of this chapter.



[50 FR 15330, Apr. 17, 1985; 50 FR 41886, Oct. 16, 1985, as amended at 

53 FR 6648, Mar. 2, 1988. Redesignated at 64 FR 66279, Nov. 24, 1999]