[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: 42CFR476.93]



[Page 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.  476.93  Opportunity to discuss proposed initial denial 



determination and changes as a result of a DRG validation.



    Before a QIO reaches an initial denial determination or makes a 

change as a result of a DRG validation, it must--

    (a) Promptly notify the provider or supplier and the patient's 

attending physician (or other attending health care practitioner) of the 

proposed determination or DRG change; and

    (b) Afford an opportunity for the provider or supplier and the 

physician (or other attending health care practitioner) to discuss the 

matter with the QIO physician advisor and to explain the nature of the 

patient's need for health care services, including all factors which 

preclude treatment of the patient as an outpatient or in an alternative 

level of inpatient care.