§476.96. Review period and reopening of initial denial determinations and changes as a result of DRG validations.
42 C.F.R. § 476.96
General timeframe. A QIO or its subcontractor—
Within one year of the date of the claim containing the service in question, may review and deny payment; and
Within one year of the date of its decision, may reopen an initial denial determination or a change as a result of a DRG validation.
Extended timeframes.
An initial denial determination or change as a result of a DRG validation may be made after one year but within four years of the date of the claim containing the service in question, if CMS approves.
A reopening of an initial denial determination or change as a result of a DRG validation may be made after one year but within four years of the date of the QIO's decision if—
Additional information is received on the patient's condition;
Reviewer error occurred in interpretation or application of Medicare coverage policy or review criteria;
There is an error apparent on the face of the evidence upon which the initial denial or DRG validation was based; or
There is a clerical error in the statement of the initial denial determination or change as a result of a DRG validation.
Fraud and abuse.
A QIO or its subcontractor may review and deny payment anytime there is a finding that the claim for service involves fraud or a similar abusive practice that does not support a finding of fraud.
An initial denial determination or change as a result of a DRG validation may be reopened and revised anytime there is a finding that it was obtained through fraud or a similar abusive practice that does not support a finding of fraud.
Notes, amendments, and revision history
Source
Source: 50 FR 15330, Apr. 17, 1985, unless otherwise noted. Redesignated at 64 FR 66279, Nov. 24, 1999.
Authority
Authority: 42 U.S.C. 1302 and 1395hh.
Source
Source: 44 FR 32081, June 4, 1979, unless otherwise noted. Redesignated at 64 FR 66279, Nov. 24, 1999.