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 473 - RECONSIDERATIONS AND APPEALS |
Subpart B - Utilization and Quality Control Peer Review Organization (PRO) Reconsiderations and Appeals |
§ 473.24 - Opportunity for a party to obtain and submit information.
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(a) Subject to the rules concerning disclosure of PRO information in section 1160 of the Act, at the request of a
provider, practitioner or beneficiary, the PRO must provide an opportunity for examination of the material upon which the initial denial determination was based. The PRO may not furnish a provider, practitioner or beneficiary with— (1) A record of the PRO deliberation; or
(2) The identity of the PRO review coordinators, physician advisors, or consultants who assisted in the initial denial determination without their consent.
(b) The PRO may require the requester to pay a reasonable fee for the reproduction of the material requested.
(c) The PRO must provide a party with an opportunity to submit new evidence before the reconsidered determination is made.