[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: 42CFR476.90]



[Page 472-473]

 

                         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.  476.90  Lack of cooperation by a health care facility or 



practitioner.



    (a) If a health care facility or practitioner refuses to allow a QIO 

to enter and perform the duties and functions required under its 

contract with CMS, the QIO may--

    (1) Determine that the health care facility or practitioner has 

failed to comply with the requirements of Sec.  474.30(c) of this 

chapter and report the matter to the HHS Inspector General; or

    (2) Issue initial denial determinations for those claims it is 

unable to review, make the determination that financial liability will 

be assigned to the health care facility, and report the matter to the 

HHS Inspector General.

    (b) If a QIO provides a facility with sufficient notice and a 

reasonable amount of time to respond to a request for information about 

a claim, and if



[[Page 473]]



the facility does not respond in a timely manner, the QIO will deny the 

claim.