§ 417.605 - Immediate QIO review of a determination of noncoverage of inpatient hospital care.

Link to an amendment published at 70 FR 4713, Jan. 28, 2005.

(a) Right to review. A Medicare enrollee who disagrees with a determination made by an HMO, CMP, or a hospital that inpatient care is no longer necessary may remain in the hospital and may (directly or through his or her authorized representative) request immediate QIO review of the determination.

(b) Procedures. For the immediate QIO review process, the following rules apply:

(1) The enrollee or authorized representative must submit the request for immediate review—

(i) To the QIO that has an agreement with the hospital under § 466.78 of this chapter;

(ii) In writing or by telephone; and

(iii) By noon of the first working day after receipt of the written notice of the determination that the hospital stay is no longer necessary.

(2) On the date it receives the enrollee's request, the QIO must notify the HMO or CMP that a request for immediate review has been filed.

(3) The HMO or CMP must supply any information that the QIO requires to conduct its review and must make it available, by phone or in writing, by the close of business of the first full working day immediately following the day the enrollee submits the request for review.

(4) In response to a request from the HMO or CMP, the hospital must submit medical records and other pertinent information to the QIO by close of business of the first full working day immediately following the day the HMO or CMP makes its request.

(5) The QIO must solicit the views of the enrollee who requested the immediate QIO review (or the enrollee's representative).

(6) The QIO must make a determination and notify the enrollee, the hospital, and the HMO or CMP by close of business of the first working day after it receives the information from the hospital, or the HMO or CMP, or both.

(c) Financial responsibility. (1) General rule. Except as provided in paragraph (c)(2) of this section, the HMO or CMP continues to be financially responsible for the costs of the hospital stay until noon of the calendar day following the day the QIO notifies the enrollee of its review determination.

(2) Exception. The hospital may not charge the HMO or CMP (or the enrollee) if—

(i) It was the hospital (acting on behalf of the enrollee) that filed the request for immediate QIO review; and

(ii) The QIO upholds the noncoverage determination made by the HMO or CMP.

Effective Date Note:

At 70 FR 4713, Jan. 28, 2005, § 417.605 was removed, effective January 1, 2006.