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Code of Federal Regulations (Last Updated: November 8, 2024) |
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Title 42 - Public Health |
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Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services |
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SubChapter F - Quality Improvement Organizations |
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Part 476 - Quality Improvement Organization Review |
| Subpart A - General Provisions |
| § 476.1 - Definitions. |
| Subpart B - XXX |
| Disclosure of Confidential Information |
| § 476.131 - Access to medical records for the monitoring of PROs. |
| § 476.132 - Disclosure of information about patients. |
| § 476.133 - Disclosure of information about practitioners, reviewers and institutions. |
| § 476.134 - Verification and amendment of PRO information. |
| § 476.135 - Disclosure necessary to perform review responsibilities. |
| § 476.136 - Disclosure to intermediaries and carriers. |
| § 476.137 - Disclosure to Federal and State enforcement agencies responsible for the investigation or identification of fraud or abuse of the Medicare or Medicaid programs. |
| § 476.138 - Disclosure for other specified purposes. |
| § 476.139 - Disclosure of PRO deliberations and decisions. |
| § 476.141 - Disclosure of PRO interpretations on the quality of health care. |
| § 476.142 - Disclosure of sanction reports. |
| § 476.143 - PRO involvement in shared health data systems. |
| General Provisions |
| § 476.101 - Scope and definitions. |
| § 476.103 - Statutory bases for disclosure of information. |
| § 476.105 - Notice of disclosures made by a PRO. |
| § 476.106 - Exceptions to PRO notice requirements. |
| § 476.107 - Limitations on redisclosure. |
| § 476.108 - Penalties for unauthorized disclosure. |
| § 476.109 - Applicability of other statutes and regulations. |
| PRO Access to Information |
| § 476.111 - PRO access to records and information of institutions and practitioners. |
| § 476.112 - PRO access to records and information of intermediaries and carriers. |
| § 476.113 - PRO access to information collected for PRO purposes. |
| § 476.114 - Limitation on data collection. |
| Disclosure of Nonconfidential Information |
| § 476.121 - Optional disclosure of nonconfidential information. |
| PRO Responsibilities |
| § 476.115 - Requirements for maintaining confidentiality. |
| § 476.116 - Notice to individuals and institutions under review. |
| Subpart C - Review Responsibilities of Quality Improvement Organizations (QIOs) |
| PRO Review Functions |
| General Provisions |
| § 476.70 - Statutory bases and applicability. |
| § 476.71 - QIO review requirements. |
| § 476.72 - Review of the quality of care of risk-basis health maintenance organizations and competitive medical plans. |
| § 476.73 - Notification of QIO designation and implementation of review. |
| § 476.74 - General requirements for the assumption of review. |
| § 476.76 - Cooperation with health care facilities. |
| § 476.78 - Responsibilities of providers and practitioners. |
| § 476.80 - Coordination with Medicare administrative contractors, fiscal intermediaries, and carriers |
| § 476.82 - Continuation of functions not assumed by QIOs. |
| QIO Review Functions |
| § 476.83 - Initial denial determinations. |
| § 476.84 - Changes as a result of DRG validation. |
| § 476.85 - Conclusive effect of QIO initial denial determinations and changes as a result of DRG validations. |
| § 476.86 - Correlation of Title XI functions with Title XVIII functions. |
| § 476.88 - Examination of the operations and records of health care facilities and practitioners. |
| § 476.90 - Lack of cooperation by a provider or practitioner. |
| § 476.93 - Opportunity to discuss proposed initial denial determination and changes as a result of a DRG validation. |
| § 476.94 - Notice of QIO initial denial determination and changes as a result of a DRG validation. |
| § 476.96 - Review period and reopening of initial denial determinations and changes as a result of DRG validations. |
| § 476.98 - Reviewer qualifications and participation. |
| § 476.100 - Use of norms and criteria. |
| § 476.102 - Involvement of health care practitioners other than physicians. |
| § 476.104 - Coordination of activities. |
| § 476.110 - Use of immediate advocacy to resolve oral beneficiary complaints. |
| § 476.120 - Submission of written beneficiary complaints. |
| § 476.130 - Beneficiary complaint review procedures. |
| § 476.140 - Beneficiary complaint reconsideration procedures. |
| § 476.150 - Abandoned complaints and reopening rights. |
| § 476.160 - General quality of care review procedures. |
| § 476.170 - General quality of care reconsideration procedures. |