[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: 42CFR478.28]



[Page 479]

 

                         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.  478.28  Qualifications of a reconsideration reviewer.



    A reconsideration reviewer must be someone who is--

    (a) Qualified under Sec.  466.98 of this chapter to make an initial 

determination.

    (b) Not the individual who made the initial denial determination.

    (c) A specialist in the type of services under review, except where 

meeting this requirement would compromise the effectiveness or 

efficiency of QIO review.