---
kind: "section"
citation: "42 C.F.R. § 478.12"
title: "42"
number: "478.12"
heading: "Statutory basis."
url: "https://uscodex.org/cfr/42/478.12"
---

# §478.12. Statutory basis.

- (a) Under section 1154 of the Act, a QIO may make an initial determination that services furnished or proposed to be furnished are not reasonable, necessary, or delivered in the most appropriate setting.
- (b) **Under section 1155 of the Act, the following rules apply—**
  - (1) A Medicare beneficiary, a provider, or an attending practitioner who is dissatisfied with an initial denial determination under [paragraph (a)](#a) of this section is entitled to a reconsideration by the QIO that made that determination.
  - (2) **The beneficiary is also entitled to the following—**
    - (i) A hearing by an administrative law judge if $200 or more is still in controversy after a reconsidered determination.
    - (ii) Judicial review if $2000 or more is still in controversy after a final determination by the Department.
- (c) Under section 1866(a)(1)(F) of the Act, a hospital that is reimbursed by the Medicare program must maintain an agreement with a QIO under which the QIO reviews the validity of diagnostic information furnished by the hospital.

## Notes

### Amendments

[50 FR 15372, Apr. 17, 1985, as amended at 60 FR 50442, Sept. 29, 1995. Redesignated at 64 FR 66279, Nov. 24, 1999]

### Source

Source: 50 FR 15372, Apr. 17, 1985, unless otherwise noted. Redesignated at 64 FR 66279, Nov. 24, 1999.

### Authority

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh).

### Amendments

[50 FR 15372, Apr. 17, 1985, as amended at 60 FR 50442, Sept. 29, 1995. Redesignated at 64 FR 66279, Nov. 24, 1999]