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Home Page > Executive Branch > Code of Federal Regulations > Electronic Code of Federal Regulations
e-CFR Data is current as of February 4, 2010
TITLE 42--Public Health
CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER F--QUALITY IMPROVEMENT ORGANIZATIONS
PART 476--UTILIZATION AND QUALITY CONTROL REVIEW
Subpart A--GENERAL PROVISIONS
Subpart B--[RESERVED]
Subpart C--REVIEW RESPONSIBILITIES OF UTILIZATION AND QUALITY CONTROL QUALITY IMPROVEMENT ORGANIZATIONS (QIOS)
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| Statutory bases and applicability. |
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| Review of the quality of care of risk-basis health maintenance organizations and competitive medical plans. |
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| Notification of QIO designation and implementation of review. |
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| General requirements for the assumption of review. |
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| Cooperation with health care facilities. |
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| Responsibilities of health care facilities. |
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| Coordination with Medicare fiscal intermediaries and carriers. |
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| Continuation of functions not assumed by QIOs. |
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| Initial denial determinations. |
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| Changes as a result of DRG validation. |
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| Conclusive effect of QIO initial denial determinations and changes as a result of DRG validations. |
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| Correlation of Title XI functions with Title XVIII functions. |
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| Examination of the operations and records of health care facilities and practitioners. |
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| Lack of cooperation by a health care facility or practitioner. |
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| Opportunity to discuss proposed initial denial determination and changes as a result of a DRG validation. |
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| Notice of QIO initial denial determination and changes as a result of a DRG validation. |
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| Review period and reopening of initial denial determinations and changes as a result of DRG validations. |
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| Reviewer qualifications and participation. |
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| Use of norms and criteria. |
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| Involvement of health care practitioners other than physicians. |
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| Coordination of activities. |
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