[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: 42CFR478.32]



[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.  478.32  Time limits for issuance of the reconsidered determination.



    (a) Beneficiaries. If a beneficiary files a timely request for 

reconsideration of an initial denial determination, the QIO must 

complete its reconsidered determination and send written notice to the 

beneficiary within the following time limits--

    (1) Within three working days after the QIO receives the request for 

reconsideration if--

    (i) The beneficiary is still an inpatient in a hospital for the stay 

in question when the QIO receives the request for reconsideration; or

    (ii) The initial determination relates to institutional services for 

which admission to the institution is sought, the initial determination 

was made before the patient was admitted to the institution; and a 

request was submitted timely for an expedited reconsideration.

    (2) Within 10 working days after the QIO receives the request for 

reconsideration if the beneficiary is still an inpatient in a SNF for 

the stay in question when the QIO receives the request for 

reconsideration.

    (3) Within 30 working days after the QIO receives the request for 

reconsideration if--

    (i) The initial determination concerns ambulatory or 

noninstitutional services;

    (ii) The beneficiary is no longer an inpatient in a hospital or SNF 

for the stay in question; or

    (iii) The beneficiary does not submit a request for expedited 

reconsideration timely.

    (b) Providers or practitioners. If the provider or practitioner 

files a request for reconsideration of an initial determination, the QIO 

must complete its reconsidered determination and send written notice to 

the provider or practitioner within 30 working days.