Code of Federal Regulations (Last Updated: July 5, 2024) |
Title 42 - Public Health |
Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services |
SubChapter D - State Children'S Health Insurance Programs (Schips) |
Part 466 - UTILIZATION AND QUALITY CONTROL REVIEW |
Subpart C - Review Responsibilities of Utilization and Quality Control Peer Review Organizations (PROs) |
PRO Review Functions |
§ 466.93 - Opportunity to discuss proposed initial denial determination and changes as a result of a DRG validation.
Latest version.
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Before a PRO reaches an initial denial determination or makes a change as a result of a DRG validation, it must—
(a) Promptly notify the provider or supplier and the patient's attending physician (or other attending health care practitioner) of the proposed determination or DRG change; and
(b) Afford an opportunity for the provider or supplier and the physician (or other attending health care practitioner) to discuss the matter with the PRO physician advisor and to explain the nature of the patient's need for health care services, including all factors which preclude treatment of the patient as an outpatient or in an alternative level of inpatient care.