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Code of Federal Regulations (Last Updated: July 5, 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 D - State Children'S Health Insurance Programs (Schips) |
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Part 473 - RECONSIDERATIONS AND APPEALS |
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Subpart B - Utilization and Quality Control Peer Review Organization (PRO) Reconsiderations and Appeals |
§ 473.15 - PRO review of changes resulting from DRG validation.
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(a)
General rules. (1) A provider or practitioner dissatisfied with a change to the diagnostic or procedural coding information made by a PRO 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 PRO 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 PRO reconsideration or reopening also apply to PRO 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.