Title 42, Part 476 — Quality Improvement Organization Review

Definitions.

Statutory bases and applicability.

QIO review requirements.

Notification of QIO designation and implementation of review.

General requirements for the assumption of review.

Cooperation with health care facilities.

Responsibilities of providers and practitioners.

Coordination with Medicare administrative contractors, fiscal intermediaries, and carriers

Continuation of functions not assumed by QIOs.

Initial denial determinations.

Changes as a result of DRG validation.

Conclusive effect of QIO initial denial determinations and changes as a result of DRG validations.

Correlation of Title XI functions with Title XVIII functions.

Examination of the operations and records of health care facilities and practitioners.

Lack of cooperation by a provider or practitioner.

Opportunity to discuss proposed initial denial determination and changes as a result of a DRG validation.

Notice of QIO initial denial determination and changes as a result of a DRG validation.

Review period and reopening of initial denial determinations and changes as a result of DRG validations.

Reviewer qualifications and participation.

Use of norms and criteria.

Involvement of health care practitioners other than physicians.

Coordination of activities.

Use of immediate advocacy to resolve oral beneficiary complaints.

Submission of written beneficiary complaints.

Beneficiary complaint review procedures.

Beneficiary complaint reconsideration procedures.

Abandoned complaints and reopening rights.

General quality of care review procedures.

General quality of care reconsideration procedures.