42 C.F.R. § 478.40 Beneficiary's right to a hearing.
Title 42 - Public Health
(a) Amount in controversy. If the amount in controversy is at least $200, a beneficiary (but not a provider or practitioner) who is dissatisfied with a QIO reconsidered determination may obtain a hearing by an administrative law judge (ALJ) of the Office of Hearings and Appeals of the SSA. (b) Subject matter. A beneficiary has a right to a hearing on the following issues: (1) Reasonableness of the services. (2) Medical necessity of the services. (3) Appropriateness of the setting in which the services were furnished. (c) Governing provisions. The provisions of subpart G, Reconsiderations and Appeals under the Hospital Insurance Program, of part 405 of this chapter apply to hearings and appeals under this subpart unless they are inconsistent with specific provisions in this subpart. References in subpart G to initial and reconsidered determinations made by an intermediary, carrier, or CMS should be read to mean initial and reconsidered determinations made by a QIO. [50 FR 15372, Apr. 17, 1985; 50 FR 41887, Oct. 16, 1985. Redesignated at 64 FR 66279, Nov. 24, 1999]
Title 42: Public Health
PART 478—RECONSIDERATIONS AND APPEALS
Subpart B—Utilization and Quality Control Quality Improvement Organization (QIO) Reconsiderations and Appeals
§ 478.40 Beneficiary's right to a hearing.
