42 C.F.R. § 476.93 Opportunity to discuss proposed initial denial determination and changes as a result of a DRG validation.
Title 42 - Public Health
Before a QIO reaches an initial denial determination or makes a change as a result of a DRG validation, it must— (a) Promptly notify the provider or supplier and the patient's attending physician (or other attending health care practitioner) of the proposed determination or DRG change; and (b) Afford an opportunity for the provider or supplier and the physician (or other attending health care practitioner) to discuss the matter with the QIO physician advisor and to explain the nature of the patient's need for health care services, including all factors which preclude treatment of the patient as an outpatient or in an alternative level of inpatient care.
Title 42: Public Health
PART 476—UTILIZATION AND QUALITY CONTROL REVIEW
Subpart C—Review Responsibilities of Utilization and Quality Control Quality Improvement Organizations (QIOs)
QIO Review Functions
§ 476.93 Opportunity to discuss proposed initial denial determination and changes as a result of a DRG validation.
