[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: 42CFR478.12]



[Page 476-477]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 478_RECONSIDERATIONS AND APPEALS--Table of Contents

 

     Subpart B_Utilization and Quality Control Quality Improvement 

             Organization (QIO) Reconsiderations and Appeals

 

Sec.  478.12  Statutory basis.



    (a) Under section 1154 of the Act, a QIO may make an initial 

determination that services furnished or proposed to be furnished are 

not reasonable, necessary, or delivered in the most appropriate setting.

    (b) Under section 1155 of the Act, the following rules apply:



[[Page 477]]



    (1) A Medicare beneficiary, a provider, or an attending practitioner 

who is dissatisfied with an initial denial determination under paragraph 

(a) of this section is entitled to a reconsideration by the QIO that 

made that determination.

    (2) The beneficiary is also entitled to the following:

    (i) A hearing by an administrative law judge if $200 or more is 

still in controversy after a reconsidered determination.

    (ii) Judicial review if $2000 or more is still in controversy after 

a final determination by the Department.

    (c) Under section 1866(a)(1)(F) of the Act, a hospital that is 

reimbursed by the Medicare program must maintain an agreement with a QIO 

under which the QIO reviews the validity of diagnostic information 

furnished by the hospital.



[50 FR 15372, Apr. 17, 1985, as amended at 60 FR 50442, Sept. 29, 1995. 

Redesignated at 64 FR 66279, Nov. 24, 1999]