[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: 42CFR476.96]



[Page 474]

 

                         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.  476.96  Review period and reopening of initial denial 



determinations and changes as a result of DRG validations.



    (a) General timeframe. A QIO or its subcontractor--

    (1) Within one year of the date of the claim containing the service 

in question, may review and deny payment; and

    (2) Within one year of the date of its decision, may reopen an 

initial denial determination or a change as a result of a DRG 

validation.

    (b) Extended timeframes. (1) An initial denial determination or 

change as a result of a DRG validation may be made after one year but 

within four years of the date of the claim containing the service in 

question, if CMS approves.

    (2) A reopening of an initial denial determination or change as a 

result of a DRG validation may be made after one year but within four 

years of the date of the QIO's decision if--

    (i) Additional information is received on the patient's condition;

    (ii) Reviewer error occurred in interpretation or application of 

Medicare coverage policy or review criteria;

    (iii) There is an error apparent on the face of the evidence upon 

which the initial denial or DRG validation was based; or

    (iv) There is a clerical error in the statement of the initial 

denial determination or change as a result of a DRG validation.

    (c) Fraud and abuse. (1) A QIO or its subcontractor may review and 

deny payment anytime there is a finding that the claim for service 

involves fraud or a similar abusive practice that does not support a 

finding of fraud.

    (2) An initial denial determination or change as a result of a DRG 

validation may be reopened and revised anytime there is a finding that 

it was obtained through fraud or a similar abusive practice that does 

not support a finding of fraud.