42 C.F.R. § 422.622 Requesting immediate QIO review of noncoverage of inpatient hospital care.
Title 42 - Public Health
(a) Enrollee's right to review or reconsideration. (1) An enrollee who wishes to appeal a determination by an MA organization or hospital that inpatient care is no longer necessary must request immediate QIO review of the determination in accordance with paragraph (b) of this section. An enrollee who requests immediate QIO review may remain in the hospital with no additional financial liability as specified in paragraph (c) of this section. (2) An enrollee who fails to request immediate QIO review in accordance with the procedures in paragraph (b) of this section may request expedited reconsideration by the MA organization as described in §422.584, but the financial liability rules of paragraph (c) of this section do not apply. (b) Procedures enrollee must follow. For the immediate QIO review process, the following rules apply: (1) The enrollee must submit the request for immediate review— (i) To the QIO that has an agreement with the hospital under parts 476 and 478 of this chapter. (ii) In writing or by telephone; and (iii) By noon of the first working day after he or she receives written notice that the MA organization or hospital has determined that the hospital stay is no longer necessary. (2) On the date it receives the enrollee's request, the QIO must notify the MA organization that the enrollee has filed a request for immediate review. (3) The MA organization must supply any information that the QIO requires to conduct its review and must make it available, by phone or in writing, by the close of business of the first full working day immediately following the day the enrollee submits the request for review. (4) In response to a request from the MA organization, the hospital must submit medical records and other pertinent information to the QIO by close of business of the first full working day immediately following the day the organization makes its request. (5) The QIO must solicit the views of the enrollee who requested the immediate QIO review. (6) The QIO must make a determination and notify the enrollee, the hospital, and the MA organization by close of business of the first working day after it receives all necessary information from the hospital, or the organization, or both. (c) Liability for hospital costs—(1) When the MA organization determines that hospital services are not, or are no longer, covered. (i) Except as provided in paragraph (c)(1)(ii) of this section, if the MA organization authorized coverage of the inpatient admission directly or by delegation (or the admission constitutes emergency or urgently needed care, as described in §§422.2 and 422.112(c)), the organization continues to be financially responsible for the costs of the hospital stay when a timely appeal is filed under paragraph (a)(1) of this section until noon of the calendar day following the day the QIO notifies the enrollee of its review determination. If coverage of the hospital admission was never approved by the MA organization (or the admission does not constitute emergency or urgently needed care, as described in §§422.2 and 422.112(c)), the MA organization is liable for the hospital costs only if it is determined on appeal that the hospital stay should have been covered under the MA plan. (ii) The hospital may not charge the MA organization (or the enrollee) if— (A) It was the hospital (acting on behalf of the enrollee) that filed the request for immediate QIO review; and (B) The QIO upholds the noncoverage determination made by the MA organization. (2) When the hospital determines that hospital services are no longer required. If the hospital determines that inpatient hospital services are no longer necessary, and the enrollee could not reasonably be expected to know that the services would not be covered, the hospital may not charge the enrollee for inpatient services received before noon of the calendar day following the day the QIO notifies the enrollee of its review determination. [63 FR 35107, June 26, 1998; 63 FR 52614, Oct. 1, 1998, as amended at 70 FR 4740, Jan. 28, 2005; 70 FR 52027, Sept. 1, 2005]
Title 42: Public Health
PART 422—MEDICARE ADVANTAGE PROGRAM
Subpart M—Grievances, Organization Determinations and Appeals
§ 422.622 Requesting immediate QIO review of noncoverage of inpatient hospital care.
