42 C.F.R. § 478.15 QIO review of changes resulting from DRG validation.
Title 42 - Public Health
(a) General rules. (1) A provider or practitioner dissatisfied with a change to the diagnostic or procedural coding information made by a QIO as a result of DRG validation under section 1866(a)(1)(F) of the Act is entitled to a review of that change if— (i) The change caused an assignment of a different DRG; and (ii) Resulted in a lower payment. (2) A beneficiary may obtain a review of a QIO DRG coding change only if that change results in noncoverage of a furnished service. (3) The individual who reviews changes in DRG procedural or diagnostic information must be a physician, and the individual who reviews changes in DRG coding must be qualified through training and experience with ICD–9–CM coding. (b) Procedures. Procedures described in §§473.18 through 473.36, and 473.48 (a) and (c) for a QIO reconsideration or reopening also apply to QIO review of a DRG coding change. (c) Finality of review. No additional review or appeal for matters governed by paragraph (a) of this section is available. [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
§ 478.15 QIO review of changes resulting from DRG validation.
