[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: 42CFR478.40]



[Page 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.  478.40  Beneficiary's right to a hearing.



    (a) Amount in controversy. If the amount in controversy is at least 

$200, a beneficiary (but not a provider or practitioner) who is 

dissatisfied with a QIO reconsidered determination may obtain a hearing 

by an administrative law judge (ALJ) of the Office of Hearings and 

Appeals of the SSA.

    (b) Subject matter. A beneficiary has a right to a hearing on the 

following issues:

    (1) Reasonableness of the services.

    (2) Medical necessity of the services.

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

furnished.

    (c) Governing provisions. The provisions of subpart G, 

Reconsiderations and Appeals under the Hospital Insurance Program, of 

part 405 of this chapter apply to hearings and appeals under this 

subpart unless they are inconsistent with specific provisions in this 

subpart. References in subpart G 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]