---
kind: "section"
citation: "42 C.F.R. § 476.96"
title: "42"
number: "476.96"
heading: "Review period and reopening of initial denial determinations and changes as a result of DRG validations."
url: "https://uscodex.org/cfr/42/476.96"
---

# §476.96. Review period and reopening of initial denial determinations and changes as a result of DRG validations.

- (a) **General timeframe.** A QIO or its subcontractor—
  - (1) Within one year of the date of the claim containing the service in question, may review and deny payment; and
  - (2) 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.
- (b) **Extended timeframes.**
  - (1) 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.
  - (2) 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—
    - (i) Additional information is received on the patient's condition;
    - (ii) Reviewer error occurred in interpretation or application of Medicare coverage policy or review criteria;
    - (iii) There is an error apparent on the face of the evidence upon which the initial denial or DRG validation was based; or
    - (iv) There is a clerical error in the statement of the initial denial determination or change as a result of a DRG validation.
- (c) **Fraud and abuse.**
  - (1) 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.
  - (2) 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

### 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.