[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: 42CFR478.14]



[Page 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.  478.14  Applicability.



    (a) Basic provision. This subpart applies to reconsiderations and 

hearings of a QIO initial denial determination involving the following 

issues:

    (1) Reasonableness of services.

    (2) Medical necessity of services.

    (3) Appropriateness of the inpatient setting in which services were 

furnished or are proposed to be furnished.

    (b) Concurrent appeal. A reconsideration or hearing provided under 

this subpart fulfills the requirements of any other review, hearing, or 

appeal under the Act to which a party may be entitled with respect to 

the same issues.

    (c) Nonapplicability of rules to related determinations. (1) A QIO 

may not reconsider its decision whether to grant grace days.

    (2) Limitation of liability determinations on excluded coverage of 

certain services are made under section 1879 of the Act. Initial 

determinations under section 1879 and further appeals are governed by 

the reconsideration and appeal procedures in part 405, subpart G of this 

chapter for determinations under Medicare Part A, and part 405, subpart 

H of this chapter for determinations under Medicare Part B. References 

in those subparts to initial and reconsidered determinations made by an 

intermediary, carrier or CMS should be read to mean initial and 

reconsidered determinations made by a QIO.



[50 FR 15372, Apr. 17, 1985; 50 FR 41887, Oct. 16, 1985. Redesignated at 

64 FR 66279, Nov. 24, 1999]