[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: 42CFR480.133]



[Page 489-490]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 480_ACQUISITION, PROTECTION, AND DISCLOSURE QUALITY IMPROVEMENT 

 

     Subpart B_Utilization and Quality Control Quality Improvement 

                          Organizations (QIOs)

 

Sec.  480.133  Disclosure of information about practitioners, reviewers 



and institutions.



    (a) General requirements for disclosure. Except as specified in 

paragraph (b) of this section, the following provisions are required of 

the QIO.

    (1) Disclosure to the identified individual or institution. A QIO 

must disclose, to particular practitioners, reviewers and institutions, 

information about themselves, upon request, and may disclose it to them 

without a request.

    (2) Disclosure to others. (i) A QIO must disclose to an institution, 

upon request, information on a practitioner to the extent that the 

information displays practice or performance patterns of the 

practitioner in that institution.

    (ii) In accordance with section 1160 of the Act, a QIO must disclose 

information that displays practice or performance patterns of a 

practitioner or institution in accordance with the procedures for 

disclosures specified in Sec. Sec.  480.137 and 480.138 to--

    (A) Federal and State agencies that are responsible for the 

investigation of fraud and abuse of the Medicare or Medicaid programs, 

and

    (B) Federal and State agencies that are responsible for licensing 

and certification of practitioners and providers.

    (iii) A QIO may disclose to any person, agency, or organization 

information on a particular practitioner or reviewer at the written 

request of or with the written consent of that practitioner or reviewer. 

The recipient of the information has the same redisclosure rights and 

responsibilities as the requesting or consenting practitioner or 

reviewer as provided under this Subpart B.

    (b) Exceptions. (1) If the request is in connection with an initial 

denial determination or a change resulting from a diagnostic related 

group (DRG) coding validation under Part 466 of this subchapter, the QIO 

must provide only the



[[Page 490]]



information used to support that determination in accordance with the 

procedures for disclosure of information relating to determinations 

under Sec.  473.24.

    (2) A QIO must disclose information regarding QIO deliberations only 

as specified in Sec.  480.139(a).

    (3) A QIO must disclose quality review study information only as 

specified in Sec.  480.140.



[50 FR 15359, Apr. 17, 1885, as amended at 52 FR 37458, Oct. 7, 1987; 52 

FR 47004, Dec. 11, 1987. Redesignated at 64 FR 66279, Nov. 24, 1999, as 

amended at 69 FR 49266, 29267, Aug. 11, 2004]