[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: 42CFR478.34]



[Page 479-480]

 

                         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.  478.34  Notice of a reconsidered determination.



    (a) Notice to parties. A written notice of a QIO reconsidered 

determination must contain the following;

    (1) The basis for the reconsidered determination.

    (2) A detailed rationale for the reconsidered determination.

    (3) A statement explaining the Medicare payment consequences of the 

reconsidered determination.



[[Page 480]]



    (4) A statement informing the parties of their appeal rights, 

including the information concerning what must be included in the 

request for hearing, the amount in controversy, locations for submitting 

a request for an administrative hearing and the time period for filing a 

request.

    (b) Notice to payers. (1) A QIO must provide written notice of its 

reconsidered determination to the appropriate Medicare intermediary or 

carrier within 30 days if the initial determination is modified or 

reversed.

    (2) This notice must contain adequate information to allow the 

intermediary or carrier to locate the claim file. This must include the 

name of the beneficiary, the Health Insurance Claim Number, the name of 

the provider, date of admission, and dates or services for which 

Medicare payment will not be made.