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Code of Federal Regulations (Last Updated: May 6, 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 |
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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. |