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Title 42
Volume 4 CHAPTER IV SUBCHAP F
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Title 42
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Volume 4
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Chapter IV
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Subchapter F
Subchapter F - Quality Improvement Organizations
42:4.0.1.4.17
PART 475
PART 475 - QUALITY IMPROVEMENT ORGANIZATIONS
42:4.0.1.4.17.1
SUBPART A
Subpart A - General Provisions
42:4.0.1.4.17.1.182.1
SECTION 475.1
475.1 Definitions.
42:4.0.1.4.17.2
SUBPART B
Subpart B [Reserved]
42:4.0.1.4.17.3
SUBPART C
Subpart C - Quality Improvement Organizations
42:4.0.1.4.17.3.182.1
SECTION 475.100
475.100 Scope and applicability.
42:4.0.1.4.17.3.182.2
SECTION 475.101
475.101 Eligibility requirements for QIO contracts.
42:4.0.1.4.17.3.182.3
SECTION 475.102
475.102 Requirements for performing case reviews.
42:4.0.1.4.17.3.182.4
SECTION 475.103
475.103 Requirements for performing quality improvement initiatives.
42:4.0.1.4.17.3.182.5
SECTION 475.104
475.104 [Reserved]
42:4.0.1.4.17.3.182.6
SECTION 475.105
475.105 Prohibition against contracting with health care facilities, affiliates, and payor organizations.
42:4.0.1.4.17.3.182.7
SECTION 475.106
475.106 [Reserved]
42:4.0.1.4.17.3.182.8
SECTION 475.107
475.107 QIO contract awards.
42:4.0.1.4.18
PART 476
PART 476 - QUALITY IMPROVEMENT ORGANIZATION REVIEW
42:4.0.1.4.18.1
SUBPART A
Subpart A - General Provisions
42:4.0.1.4.18.1.184.1
SECTION 476.1
476.1 Definitions.
42:4.0.1.4.18.2
SUBPART B
Subpart B [Reserved]
42:4.0.1.4.18.3
SUBPART C
Subpart C - Review Responsibilities of Quality Improvement Organizations (QIOs)
42:4.0.1.4.18.3.184
SUBJGRP 184
General Provisions
42:4.0.1.4.18.3.184.1
SECTION 476.70
476.70 Statutory bases and applicability.
42:4.0.1.4.18.3.184.2
SECTION 476.71
476.71 QIO review requirements.
42:4.0.1.4.18.3.184.3
SECTION 476.73
476.73 Notification of QIO designation and implementation of review.
42:4.0.1.4.18.3.184.4
SECTION 476.74
476.74 General requirements for the assumption of review.
42:4.0.1.4.18.3.184.5
SECTION 476.76
476.76 Cooperation with health care facilities.
42:4.0.1.4.18.3.184.6
SECTION 476.78
476.78 Responsibilities of providers and practitioners.
42:4.0.1.4.18.3.184.7
SECTION 476.80
476.80 Coordination with Medicare administrative contractors, fiscal intermediaries, and carriers
42:4.0.1.4.18.3.184.8
SECTION 476.82
476.82 Continuation of functions not assumed by QIOs.
42:4.0.1.4.18.3.185
SUBJGRP 185
QIO Review Functions
42:4.0.1.4.18.3.185.9
SECTION 476.83
476.83 Initial denial determinations.
42:4.0.1.4.18.3.185.10
SECTION 476.84
476.84 Changes as a result of DRG validation.
42:4.0.1.4.18.3.185.11
SECTION 476.85
476.85 Conclusive effect of QIO initial denial determinations and changes as a result of DRG validations.
42:4.0.1.4.18.3.185.12
SECTION 476.86
476.86 Correlation of Title XI functions with Title XVIII functions.
42:4.0.1.4.18.3.185.13
SECTION 476.88
476.88 Examination of the operations and records of health care facilities and practitioners.
42:4.0.1.4.18.3.185.14
SECTION 476.90
476.90 Lack of cooperation by a provider or practitioner.
42:4.0.1.4.18.3.185.15
SECTION 476.93
476.93 Opportunity to discuss proposed initial denial determination and changes as a result of a DRG validation.
42:4.0.1.4.18.3.185.16
SECTION 476.94
476.94 Notice of QIO initial denial determination and changes as a result of a DRG validation.
42:4.0.1.4.18.3.185.17
SECTION 476.96
476.96 Review period and reopening of initial denial determinations and changes as a result of DRG validations.
42:4.0.1.4.18.3.185.18
SECTION 476.98
476.98 Reviewer qualifications and participation.
42:4.0.1.4.18.3.185.19
SECTION 476.100
476.100 Use of norms and criteria.
42:4.0.1.4.18.3.185.20
SECTION 476.102
476.102 Involvement of health care practitioners other than physicians.
42:4.0.1.4.18.3.185.21
SECTION 476.104
476.104 Coordination of activities.
42:4.0.1.4.18.3.185.22
SECTION 476.110
476.110 Use of immediate advocacy to resolve oral beneficiary complaints.
42:4.0.1.4.18.3.185.23
SECTION 476.120
476.120 Submission of written beneficiary complaints.
42:4.0.1.4.18.3.185.24
SECTION 476.130
476.130 Beneficiary complaint review procedures.
42:4.0.1.4.18.3.185.25
SECTION 476.140
476.140 Beneficiary complaint reconsideration procedures.
42:4.0.1.4.18.3.185.26
SECTION 476.150
476.150 Abandoned complaints and reopening rights.
42:4.0.1.4.18.3.185.27
SECTION 476.160
476.160 General quality of care review procedures.
42:4.0.1.4.18.3.185.28
SECTION 476.170
476.170 General quality of care reconsideration procedures.
42:4.0.1.4.19
PART 478
PART 478 - RECONSIDERATIONS AND APPEALS
42:4.0.1.4.19.1
SUBPART A
Subpart A [Reserved]
42:4.0.1.4.19.2
SUBPART B
Subpart B - Utilization and Quality Control Quality Improvement Organization (QIO) Reconsiderations and Appeals
42:4.0.1.4.19.2.186.1
SECTION 478.10
478.10 Scope.
42:4.0.1.4.19.2.186.2
SECTION 478.12
478.12 Statutory basis.
42:4.0.1.4.19.2.186.3
SECTION 478.14
478.14 Applicability.
42:4.0.1.4.19.2.186.4
SECTION 478.15
478.15 QIO review of changes resulting from DRG validation.
42:4.0.1.4.19.2.186.5
SECTION 478.16
478.16 Right to reconsideration.
42:4.0.1.4.19.2.186.6
SECTION 478.18
478.18 Location for submitting requests for reconsideration.
42:4.0.1.4.19.2.186.7
SECTION 478.20
478.20 Time limits for requesting reconsideration.
42:4.0.1.4.19.2.186.8
SECTION 478.22
478.22 Good cause for late filing of a request for a reconsideration or hearing.
42:4.0.1.4.19.2.186.9
SECTION 478.24
478.24 Opportunity for a party to obtain and submit information.
42:4.0.1.4.19.2.186.10
SECTION 478.26
478.26 Delegation of the reconsideration function.
42:4.0.1.4.19.2.186.11
SECTION 478.28
478.28 Qualifications of a reconsideration reviewer.
42:4.0.1.4.19.2.186.12
SECTION 478.30
478.30 Evidence to be considered by the reconsideration reviewer.
42:4.0.1.4.19.2.186.13
SECTION 478.32
478.32 Time limits for issuance of the reconsidered determination.
42:4.0.1.4.19.2.186.14
SECTION 478.34
478.34 Notice of a reconsidered determination.
42:4.0.1.4.19.2.186.15
SECTION 478.36
478.36 Record of reconsideration.
42:4.0.1.4.19.2.186.16
SECTION 478.38
478.38 Effect of a reconsidered determination.
42:4.0.1.4.19.2.186.17
SECTION 478.40
478.40 Beneficiary's right to a hearing.
42:4.0.1.4.19.2.186.18
SECTION 478.42
478.42 Submitting a request for a hearing.
42:4.0.1.4.19.2.186.19
SECTION 478.44
478.44 Determining the amount in controversy for a hearing.
42:4.0.1.4.19.2.186.20
SECTION 478.46
478.46 Medicare Appeals Council and judicial review.
42:4.0.1.4.19.2.186.21
SECTION 478.48
478.48 Reopening and revision of a reconsidered determination or a decision.
42:4.0.1.4.20
PART 480
PART 480 - ACQUISITION, PROTECTION, AND DISCLOSURE OF QUALITY IMPROVEMENT ORGANIZATION INFORMATION
42:4.0.1.4.20.1
SUBPART A
Subpart A [Reserved]
42:4.0.1.4.20.2
SUBPART B
Subpart B - Utilization and Quality Control Quality Improvement Organizations (QIOs)
42:4.0.1.4.20.2.191
SUBJGRP 191
General Provisions
42:4.0.1.4.20.2.191.1
SECTION 480.101
480.101 Scope and definitions.
42:4.0.1.4.20.2.191.2
SECTION 480.102
480.102 Statutory bases for acquisition and maintenance of information.
42:4.0.1.4.20.2.191.3
SECTION 480.103
480.103 Statutory bases for disclosure of information.
42:4.0.1.4.20.2.191.4
SECTION 480.104
480.104 Procedures for disclosure by a QIO.
42:4.0.1.4.20.2.191.5
SECTION 480.105
480.105 Notice of disclosures made by a QIO.
42:4.0.1.4.20.2.191.6
SECTION 480.106
480.106 Exceptions to QIO notice requirements.
42:4.0.1.4.20.2.191.7
SECTION 480.107
480.107 Limitations on redisclosure.
42:4.0.1.4.20.2.191.8
SECTION 480.108
480.108 Penalties for unauthorized disclosure.
42:4.0.1.4.20.2.191.9
SECTION 480.109
480.109 Applicability of other statutes and regulations.
42:4.0.1.4.20.2.192
SUBJGRP 192
QIO Access to Information
42:4.0.1.4.20.2.192.10
SECTION 480.111
480.111 QIO access to records and information of institutions and practitioners.
42:4.0.1.4.20.2.192.11
SECTION 480.112
480.112 QIO access to records and information of intermediaries and carriers.
42:4.0.1.4.20.2.192.12
SECTION 480.113
480.113 QIO access to information collected for QIO purposes.
42:4.0.1.4.20.2.192.13
SECTION 480.114
480.114 Limitation on data collection.
42:4.0.1.4.20.2.193
SUBJGRP 193
QIO Responsibilities
42:4.0.1.4.20.2.193.14
SECTION 480.115
480.115 Requirements for maintaining confidentiality.
42:4.0.1.4.20.2.193.15
SECTION 480.116
480.116 Notice to individuals and institutions under review.
42:4.0.1.4.20.2.194
SUBJGRP 194
Disclosure of Nonconfidential Information
42:4.0.1.4.20.2.194.16
SECTION 480.120
480.120 Information subject to disclosure.
42:4.0.1.4.20.2.194.17
SECTION 480.121
480.121 Optional disclosure of nonconfidential information.
42:4.0.1.4.20.2.195
SUBJGRP 195
Disclosure of Confidential Information
42:4.0.1.4.20.2.195.18
SECTION 480.130
480.130 Disclosure to the Department.
42:4.0.1.4.20.2.195.19
SECTION 480.131
480.131 Access to medical records for the monitoring of QIOs.
42:4.0.1.4.20.2.195.20
SECTION 480.132
480.132 Disclosure of information about patients.
42:4.0.1.4.20.2.195.21
SECTION 480.133
480.133 Disclosure of information about practitioners, reviewers and institutions.
42:4.0.1.4.20.2.195.22
SECTION 480.134
480.134 Verification and amendment of QIO information.
42:4.0.1.4.20.2.195.23
SECTION 480.135
480.135 Disclosure necessary to perform review responsibilities.
42:4.0.1.4.20.2.195.24
SECTION 480.136
480.136 Disclosure to intermediaries and carriers.
42:4.0.1.4.20.2.195.25
SECTION 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.
42:4.0.1.4.20.2.195.26
SECTION 480.138
480.138 Disclosure for other specified purposes.
42:4.0.1.4.20.2.195.27
SECTION 480.139
480.139 Disclosure of QIO deliberations and decisions.
42:4.0.1.4.20.2.195.28
SECTION 480.140
480.140 Disclosure of quality review study information.
42:4.0.1.4.20.2.195.29
SECTION 480.141
480.141 Disclosure of QIO interpretations on the quality of health care.
42:4.0.1.4.20.2.195.30
SECTION 480.142
480.142 Disclosure of sanction reports.
42:4.0.1.4.20.2.195.31
SECTION 480.143
480.143 QIO involvement in shared health data systems.
42:4.0.1.4.20.2.195.32
SECTION 480.144
480.144 Access to QIO data and information.
42:4.0.1.4.20.2.195.33
SECTION 480.145
480.145 Beneficiary authorization of use of confidential information.
42:4.0.1.4.21
PART 481
PART 481 [RESERVED]