42 CFR § 476.96 - Review period and reopening of initial denial determinations and changes as a result of DRG validations.
---
identifier: "/us/cfr/t42/s476.96"
source: "ecfr"
legal_status: "authoritative_unofficial"
title: "42 CFR § 476.96 - Review period and reopening of initial denial determinations and changes as a result of DRG validations."
title_number: 42
title_name: "Public Health"
section_number: "476.96"
section_name: "Review period and reopening of initial denial determinations and changes as a result of DRG validations."
chapter_name: "CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES"
subchapter_number: "F"
subchapter_name: "QUALITY IMPROVEMENT ORGANIZATIONS"
part_number: "476"
part_name: "QUALITY IMPROVEMENT ORGANIZATION REVIEW"
positive_law: false
currency: "2026-04-05"
last_updated: "2026-04-05"
format_version: "1.1.0"
generator: "[email protected]"
authority: "42 U.S.C. 1302 and 1395hh."
regulatory_source: "44 FR 32081, June 4, 1979, unless otherwise noted. Redesignated at 64 FR 66279, Nov. 24, 1999."
cfr_part: "476"
---
# 476.96 Review period and reopening of initial denial determinations and changes as a result of DRG validations.
(a) *General timeframe.* A QIO or its subcontractor—
(1) Within one year of the date of the claim containing the service in question, may review and deny payment; and
(2) Within one year of the date of its decision, may reopen an initial denial determination or a change as a result of a DRG validation.
(b) *Extended timeframes.* (1) An initial denial determination or change as a result of a DRG validation may be made after one year but within four years of the date of the claim containing the service in question, if CMS approves.
(2) A reopening of an initial denial determination or change as a result of a DRG validation may be made after one year but within four years of the date of the QIO's decision if—
(i) Additional information is received on the patient's condition;
(ii) Reviewer error occurred in interpretation or application of Medicare coverage policy or review criteria;
(iii) There is an error apparent on the face of the evidence upon which the initial denial or DRG validation was based; or
(iv) There is a clerical error in the statement of the initial denial determination or change as a result of a DRG validation.
(c) *Fraud and abuse.* (1) A QIO or its subcontractor may review and deny payment anytime there is a finding that the claim for service involves fraud or a similar abusive practice that does not support a finding of fraud.
(2) An initial denial determination or change as a result of a DRG validation may be reopened and revised anytime there is a finding that it was obtained through fraud or a similar abusive practice that does not support a finding of fraud.