[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: 42CFR480.137]



[Page 490-491]

 

                         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.  480.137  Disclosure to Federal and State enforcement agencies 



responsible for the investigation or identification of fraud or abuse 

of the Medicare or Medicaid programs.



    (a) Required disclosure. Except as specified in Sec. Sec.  

480.139(a) and 480.140 relating to disclosure of QIO deliberations and 

quality review study information, the QIO must disclose confidential 

information relevant to an investigation of fraud or abuse of the



[[Page 491]]



Medicare or medicaid programs, including QIO medical necessity 

determinations and other information that includes patterns of the 

practice or performance of a practitioner or institution, when a written 

request is received from a State or Federal enforcement agency 

responsible for the investigation or identification of fraud or abuse of 

the Medicare or Medicaid programs that--

    (1) Identifies the name and title of the individual initiating the 

request,

    (2) Identifies the physician or institution about which information 

is requested, and

    (3) States affirmatively that the institution or practitioner is 

currently under investigation for fraud or abuse of the Medicare or 

Medicaid programs and that the information is needed in furtherance of 

that investigation.

    (b) Optional disclosure. The QIO may provide the information 

specified in paragraph (a) of this section to Federal or State fraud and 

abuse enforcement agencies responsible for the investigation or 

identification of fraud or abuse of the Medicare or Medicaid programs, 

without a request.



[50 FR 15358, Apr. 17, 1985, as amended at 52 FR 37458, Oct. 7, 1987. 

Redesignated at 64 FR 66279, Nov. 24, 1999, as amended at 69 FR 49267, 

Aug. 11, 2004]