Title 42

Volume 4 CHAPTER IV SUBCHAP F

Subchapter F - Quality Improvement Organizations

42:4.0.1.4.17PART 475
PART 475 - QUALITY IMPROVEMENT ORGANIZATIONS
42:4.0.1.4.17.1SUBPART A
Subpart A - General Provisions
42:4.0.1.4.17.1.182.1SECTION 475.1
     475.1 Definitions.
42:4.0.1.4.17.2SUBPART B
Subpart B [Reserved]
42:4.0.1.4.17.3SUBPART C
Subpart C - Quality Improvement Organizations
42:4.0.1.4.17.3.182.1SECTION 475.100
     475.100 Scope and applicability.
42:4.0.1.4.17.3.182.2SECTION 475.101
     475.101 Eligibility requirements for QIO contracts.
42:4.0.1.4.17.3.182.3SECTION 475.102
     475.102 Requirements for performing case reviews.
42:4.0.1.4.17.3.182.4SECTION 475.103
     475.103 Requirements for performing quality improvement initiatives.
42:4.0.1.4.17.3.182.5SECTION 475.104
     475.104 [Reserved]
42:4.0.1.4.17.3.182.6SECTION 475.105
     475.105 Prohibition against contracting with health care facilities, affiliates, and payor organizations.
42:4.0.1.4.17.3.182.7SECTION 475.106
     475.106 [Reserved]
42:4.0.1.4.17.3.182.8SECTION 475.107
     475.107 QIO contract awards.
42:4.0.1.4.18PART 476
PART 476 - QUALITY IMPROVEMENT ORGANIZATION REVIEW
42:4.0.1.4.18.1SUBPART A
Subpart A - General Provisions
42:4.0.1.4.18.1.184.1SECTION 476.1
     476.1 Definitions.
42:4.0.1.4.18.2SUBPART B
Subpart B [Reserved]
42:4.0.1.4.18.3SUBPART C
Subpart C - Review Responsibilities of Quality Improvement Organizations (QIOs)
42:4.0.1.4.18.3.184SUBJGRP 184
  General Provisions
42:4.0.1.4.18.3.184.1SECTION 476.70
     476.70 Statutory bases and applicability.
42:4.0.1.4.18.3.184.2SECTION 476.71
     476.71 QIO review requirements.
42:4.0.1.4.18.3.184.3SECTION 476.73
     476.73 Notification of QIO designation and implementation of review.
42:4.0.1.4.18.3.184.4SECTION 476.74
     476.74 General requirements for the assumption of review.
42:4.0.1.4.18.3.184.5SECTION 476.76
     476.76 Cooperation with health care facilities.
42:4.0.1.4.18.3.184.6SECTION 476.78
     476.78 Responsibilities of providers and practitioners.
42:4.0.1.4.18.3.184.7SECTION 476.80
     476.80 Coordination with Medicare administrative contractors, fiscal intermediaries, and carriers
42:4.0.1.4.18.3.184.8SECTION 476.82
     476.82 Continuation of functions not assumed by QIOs.
42:4.0.1.4.18.3.185SUBJGRP 185
  QIO Review Functions
42:4.0.1.4.18.3.185.9SECTION 476.83
     476.83 Initial denial determinations.
42:4.0.1.4.18.3.185.10SECTION 476.84
     476.84 Changes as a result of DRG validation.
42:4.0.1.4.18.3.185.11SECTION 476.85
     476.85 Conclusive effect of QIO initial denial determinations and changes as a result of DRG validations.
42:4.0.1.4.18.3.185.12SECTION 476.86
     476.86 Correlation of Title XI functions with Title XVIII functions.
42:4.0.1.4.18.3.185.13SECTION 476.88
     476.88 Examination of the operations and records of health care facilities and practitioners.
42:4.0.1.4.18.3.185.14SECTION 476.90
     476.90 Lack of cooperation by a provider or practitioner.
42:4.0.1.4.18.3.185.15SECTION 476.93
     476.93 Opportunity to discuss proposed initial denial determination and changes as a result of a DRG validation.
42:4.0.1.4.18.3.185.16SECTION 476.94
     476.94 Notice of QIO initial denial determination and changes as a result of a DRG validation.
42:4.0.1.4.18.3.185.17SECTION 476.96
     476.96 Review period and reopening of initial denial determinations and changes as a result of DRG validations.
42:4.0.1.4.18.3.185.18SECTION 476.98
     476.98 Reviewer qualifications and participation.
42:4.0.1.4.18.3.185.19SECTION 476.100
     476.100 Use of norms and criteria.
42:4.0.1.4.18.3.185.20SECTION 476.102
     476.102 Involvement of health care practitioners other than physicians.
42:4.0.1.4.18.3.185.21SECTION 476.104
     476.104 Coordination of activities.
42:4.0.1.4.18.3.185.22SECTION 476.110
     476.110 Use of immediate advocacy to resolve oral beneficiary complaints.
42:4.0.1.4.18.3.185.23SECTION 476.120
     476.120 Submission of written beneficiary complaints.
42:4.0.1.4.18.3.185.24SECTION 476.130
     476.130 Beneficiary complaint review procedures.
42:4.0.1.4.18.3.185.25SECTION 476.140
     476.140 Beneficiary complaint reconsideration procedures.
42:4.0.1.4.18.3.185.26SECTION 476.150
     476.150 Abandoned complaints and reopening rights.
42:4.0.1.4.18.3.185.27SECTION 476.160
     476.160 General quality of care review procedures.
42:4.0.1.4.18.3.185.28SECTION 476.170
     476.170 General quality of care reconsideration procedures.
42:4.0.1.4.19PART 478
PART 478 - RECONSIDERATIONS AND APPEALS
42:4.0.1.4.19.1SUBPART A
Subpart A [Reserved]
42:4.0.1.4.19.2SUBPART B
Subpart B - Utilization and Quality Control Quality Improvement Organization (QIO) Reconsiderations and Appeals
42:4.0.1.4.19.2.186.1SECTION 478.10
     478.10 Scope.
42:4.0.1.4.19.2.186.2SECTION 478.12
     478.12 Statutory basis.
42:4.0.1.4.19.2.186.3SECTION 478.14
     478.14 Applicability.
42:4.0.1.4.19.2.186.4SECTION 478.15
     478.15 QIO review of changes resulting from DRG validation.
42:4.0.1.4.19.2.186.5SECTION 478.16
     478.16 Right to reconsideration.
42:4.0.1.4.19.2.186.6SECTION 478.18
     478.18 Location for submitting requests for reconsideration.
42:4.0.1.4.19.2.186.7SECTION 478.20
     478.20 Time limits for requesting reconsideration.
42:4.0.1.4.19.2.186.8SECTION 478.22
     478.22 Good cause for late filing of a request for a reconsideration or hearing.
42:4.0.1.4.19.2.186.9SECTION 478.24
     478.24 Opportunity for a party to obtain and submit information.
42:4.0.1.4.19.2.186.10SECTION 478.26
     478.26 Delegation of the reconsideration function.
42:4.0.1.4.19.2.186.11SECTION 478.28
     478.28 Qualifications of a reconsideration reviewer.
42:4.0.1.4.19.2.186.12SECTION 478.30
     478.30 Evidence to be considered by the reconsideration reviewer.
42:4.0.1.4.19.2.186.13SECTION 478.32
     478.32 Time limits for issuance of the reconsidered determination.
42:4.0.1.4.19.2.186.14SECTION 478.34
     478.34 Notice of a reconsidered determination.
42:4.0.1.4.19.2.186.15SECTION 478.36
     478.36 Record of reconsideration.
42:4.0.1.4.19.2.186.16SECTION 478.38
     478.38 Effect of a reconsidered determination.
42:4.0.1.4.19.2.186.17SECTION 478.40
     478.40 Beneficiary's right to a hearing.
42:4.0.1.4.19.2.186.18SECTION 478.42
     478.42 Submitting a request for a hearing.
42:4.0.1.4.19.2.186.19SECTION 478.44
     478.44 Determining the amount in controversy for a hearing.
42:4.0.1.4.19.2.186.20SECTION 478.46
     478.46 Medicare Appeals Council and judicial review.
42:4.0.1.4.19.2.186.21SECTION 478.48
     478.48 Reopening and revision of a reconsidered determination or a decision.
42:4.0.1.4.20PART 480
PART 480 - ACQUISITION, PROTECTION, AND DISCLOSURE OF QUALITY IMPROVEMENT ORGANIZATION INFORMATION
42:4.0.1.4.20.1SUBPART A
Subpart A [Reserved]
42:4.0.1.4.20.2SUBPART B
Subpart B - Utilization and Quality Control Quality Improvement Organizations (QIOs)
42:4.0.1.4.20.2.191SUBJGRP 191
  General Provisions
42:4.0.1.4.20.2.191.1SECTION 480.101
     480.101 Scope and definitions.
42:4.0.1.4.20.2.191.2SECTION 480.102
     480.102 Statutory bases for acquisition and maintenance of information.
42:4.0.1.4.20.2.191.3SECTION 480.103
     480.103 Statutory bases for disclosure of information.
42:4.0.1.4.20.2.191.4SECTION 480.104
     480.104 Procedures for disclosure by a QIO.
42:4.0.1.4.20.2.191.5SECTION 480.105
     480.105 Notice of disclosures made by a QIO.
42:4.0.1.4.20.2.191.6SECTION 480.106
     480.106 Exceptions to QIO notice requirements.
42:4.0.1.4.20.2.191.7SECTION 480.107
     480.107 Limitations on redisclosure.
42:4.0.1.4.20.2.191.8SECTION 480.108
     480.108 Penalties for unauthorized disclosure.
42:4.0.1.4.20.2.191.9SECTION 480.109
     480.109 Applicability of other statutes and regulations.
42:4.0.1.4.20.2.192SUBJGRP 192
  QIO Access to Information
42:4.0.1.4.20.2.192.10SECTION 480.111
     480.111 QIO access to records and information of institutions and practitioners.
42:4.0.1.4.20.2.192.11SECTION 480.112
     480.112 QIO access to records and information of intermediaries and carriers.
42:4.0.1.4.20.2.192.12SECTION 480.113
     480.113 QIO access to information collected for QIO purposes.
42:4.0.1.4.20.2.192.13SECTION 480.114
     480.114 Limitation on data collection.
42:4.0.1.4.20.2.193SUBJGRP 193
  QIO Responsibilities
42:4.0.1.4.20.2.193.14SECTION 480.115
     480.115 Requirements for maintaining confidentiality.
42:4.0.1.4.20.2.193.15SECTION 480.116
     480.116 Notice to individuals and institutions under review.
42:4.0.1.4.20.2.194SUBJGRP 194
  Disclosure of Nonconfidential Information
42:4.0.1.4.20.2.194.16SECTION 480.120
     480.120 Information subject to disclosure.
42:4.0.1.4.20.2.194.17SECTION 480.121
     480.121 Optional disclosure of nonconfidential information.
42:4.0.1.4.20.2.195SUBJGRP 195
  Disclosure of Confidential Information
42:4.0.1.4.20.2.195.18SECTION 480.130
     480.130 Disclosure to the Department.
42:4.0.1.4.20.2.195.19SECTION 480.131
     480.131 Access to medical records for the monitoring of QIOs.
42:4.0.1.4.20.2.195.20SECTION 480.132
     480.132 Disclosure of information about patients.
42:4.0.1.4.20.2.195.21SECTION 480.133
     480.133 Disclosure of information about practitioners, reviewers and institutions.
42:4.0.1.4.20.2.195.22SECTION 480.134
     480.134 Verification and amendment of QIO information.
42:4.0.1.4.20.2.195.23SECTION 480.135
     480.135 Disclosure necessary to perform review responsibilities.
42:4.0.1.4.20.2.195.24SECTION 480.136
     480.136 Disclosure to intermediaries and carriers.
42:4.0.1.4.20.2.195.25SECTION 480.137
     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.
42:4.0.1.4.20.2.195.26SECTION 480.138
     480.138 Disclosure for other specified purposes.
42:4.0.1.4.20.2.195.27SECTION 480.139
     480.139 Disclosure of QIO deliberations and decisions.
42:4.0.1.4.20.2.195.28SECTION 480.140
     480.140 Disclosure of quality review study information.
42:4.0.1.4.20.2.195.29SECTION 480.141
     480.141 Disclosure of QIO interpretations on the quality of health care.
42:4.0.1.4.20.2.195.30SECTION 480.142
     480.142 Disclosure of sanction reports.
42:4.0.1.4.20.2.195.31SECTION 480.143
     480.143 QIO involvement in shared health data systems.
42:4.0.1.4.20.2.195.32SECTION 480.144
     480.144 Access to QIO data and information.
42:4.0.1.4.20.2.195.33SECTION 480.145
     480.145 Beneficiary authorization of use of confidential information.
42:4.0.1.4.21PART 481
PART 481 [RESERVED]