Title 42

SECTION 478.32

478.32 Time limits for issuance of the reconsidered determination.

§ 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.

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