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Notes

42 C.F.R. §§ 478.18–478.36

10 sections in range

§478.18. Location for submitting requests for reconsideration.

42 C.F.R. § 478.18

(a)
Beneficiaries. Except as provided in paragraph (c) of this section concerning requests for expedited reconsideration, a beneficiary who wishes to obtain a reconsideration must submit a written request to one of the following:
(1)
The QIO or the QIO subcontractor that made the initial determination.
(2)
An SSA District Office.
(3)
A Railroad Retirement Board Office, if the beneficiary is a railroad retiree.
(b)
Others. A provider, physician or other practitioner that wishes to obtain reconsideration must submit a written request to the QIO or QIO subcontractor that made the initial determination.
(c)
Expedited reconsideration. A request for an expedited reconsideration of a preadmission denial determination must be submitted directly to the QIO.
Notes, amendments, and revision history

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).

§478.20. Time limits for requesting reconsideration.

42 C.F.R. § 478.20

(a)
Basic rules.
(1)
Except for a request for expedited reconsideration as provided in paragraph (c) of this section, or a late request with good cause under § 478.22, a dissatisfied party must file a request for reconsideration within 60 days after receipt of the notice of an initial determination.
(2)
The date of receipt of the notice of the initial determination is presumed to be five days after the date on the notice, unless there is a reasonable showing to the contrary.
(3)
A request is considered filed on the date it is postmarked.
(b)
Late filing of request. A QIO will accept a request filed after 60 days after receipt of the notice of the initial determination if the QIO finds under the criteria set forth in § 478.22 that there was good cause for the party's failure to file a timely request.
(c)
Request for expedited reconsideration. A request for an expedited reconsideration under § 478.18(c) must be submitted within three days after receipt of the notice of the initial denial determination.
Notes, amendments, and revision history

Amendments

[50 FR 15330, Apr. 17, 1985, as amended at 77 FR 68563, Nov. 15, 2012]

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 15330, Apr. 17, 1985, as amended at 77 FR 68563, Nov. 15, 2012]

§478.22. Good cause for late filing of a request for a reconsideration or hearing.

42 C.F.R. § 478.22

(a)
General Rule. In determining whether a party has good cause for not filing a request for reconsideration or hearing timely, the QIO or ALJ, respectively, must consider the following:
(1)
What circumstances kept the party from making the request on time.
(2)
Whether an action by the QIO misled the party.
(3)
Whether the party understood the requirements of the Act as affected by amendments to the Act, other legislation, or court decisions.
(b)
Examples. Examples of circumstances in which good cause may exist include, but are not limited to, the following:
(1)
A party was seriously ill and was prevented from requesting a reconsideration in person, through another person, or in writing.
(2)
There was a death or serious illness in a party's immediate family.
(3)
Important records were accidentally destroyed or damaged by fire or other cause.
(4)
A party made a diligent effort but could not find or obtain necessary relevent information within the appropriate time period.
(5)
A party requested additional information to further explain the determination within the time limit, and requested reconsideration within 60 days of receiving the explanation (or within 30 days for a Departmental Appeals Board hearing).
(6)
The QIO gave the party incorrect or incomplete information about when and how to request a reconsideration or hearing.
(7)
A party sent the request to another Government agency in good faith within the time limit, but the request did not reach an office authorized to receive the request until after the time period had expired.
(8)
Other unusual or unavoidable circumstances exist that—
(i)
Show that a party could not have known of the need to file timely; or
(ii)
Prevented a party from filing timely.
Notes, amendments, and revision history

Amendments

[50 FR 15372, Apr. 17, 1985, as amended at 61 FR 32349, June 24, 1996. 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 61 FR 32349, June 24, 1996. Redesignated at 64 FR 66279, Nov. 24, 1999]

§478.24. Opportunity for a party to obtain and submit information.

42 C.F.R. § 478.24

(a)
Subject to the rules concerning disclosure of QIO information in section 1160 of the Act, at the request of a provider, practitioner or beneficiary, the QIO must provide an opportunity for examination of the material upon which the initial denial determination was based. The QIO may not furnish a provider, practitioner or beneficiary with—
(1)
A record of the QIO deliberation; or
(2)
The identity of the QIO review coordinators, physician advisors, or consultants who assisted in the initial denial determination without their consent.
(b)
The QIO may require the requester to pay a reasonable fee for the reproduction of the material requested.
(c)
The QIO must provide a party with an opportunity to submit new evidence before the reconsidered determination is made.
Notes, amendments, and revision history

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).

§478.26. Delegation of the reconsideration function.

42 C.F.R. § 478.26

A QIO may delegate the authority to reconsider an initial determination to a nonfacility subcontractor, including the organization that made the initial determination as a QIO subcontractor.
Notes, amendments, and revision history

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).

§478.28. Qualifications of a reconsideration reviewer.

42 C.F.R. § 478.28

A reconsideration reviewer must be someone who is—
(a)
Qualified under § 476.98 of this chapter to make an initial determination.
(b)
Not the individual who made the initial denial determination.
(c)
A specialist in the type of services under review, except where meeting this requirement would compromise the effectiveness or efficiency of QIO review.
Notes, amendments, and revision history

Amendments

[50 FR 15330, Apr. 17, 1985, as amended at 77 FR 68563, Nov. 15, 2012]

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 15330, Apr. 17, 1985, as amended at 77 FR 68563, Nov. 15, 2012]

§478.30. Evidence to be considered by the reconsideration reviewer.

42 C.F.R. § 478.30

A reconsidered determination must be based on—
(a)
The information that led to the initial determination;
(b)
New information found in the medical records; or
(c)
Additional evidence submitted by a party.
Notes, amendments, and revision history

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).

§478.32. Time limits for issuance of the reconsidered determination.

42 C.F.R. § 478.32

(a)
Beneficiaries. If a beneficiary files a timely request for reconsideration of an initial denial determination, the QIO must complete its reconsidered determination and send written notice to the beneficiary within the following time limits—
(1)
Within three working days after the QIO receives the request for reconsideration if—
(i)
The beneficiary is still an inpatient in a hospital for the stay in question when the QIO receives the request for reconsideration; or
(ii)
The initial determination relates to institutional services for which admission to the institution is sought, the initial determination was made before the patient was admitted to the institution; and a request was submitted timely for an expedited reconsideration.
(2)
Within 10 working days after the QIO receives the request for reconsideration if the beneficiary is still an inpatient in a SNF for the stay in question when the QIO receives the request for reconsideration.
(3)
Within 30 working days after the QIO receives the request for reconsideration if—
(i)
The initial determination concerns ambulatory or noninstitutional services;
(ii)
The beneficiary is no longer an inpatient in a hospital or SNF for the stay in question; or
(iii)
The beneficiary does not submit a request for expedited reconsideration timely.
(b)
Providers or practitioners. If the provider or practitioner files a request for reconsideration of an initial determination, the QIO must complete its reconsidered determination and send written notice to the provider or practitioner within 30 working days.
Notes, amendments, and revision history

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).

§478.34. Notice of a reconsidered determination.

42 C.F.R. § 478.34

(a)
Notice to parties. A written notice of a QIO reconsidered determination must contain the following;
(1)
The basis for the reconsidered determination.
(2)
A detailed rationale for the reconsidered determination.
(3)
A statement explaining the Medicare payment consequences of the reconsidered determination.
(4)
A statement informing the parties of their appeal rights, including the information concerning what must be included in the request for hearing, the amount in controversy, locations for submitting a request for an administrative hearing and the time period for filing a request.
(b)
Notice to payers.
(1)
A QIO must provide written notice of its reconsidered determination to the appropriate Medicare intermediary or carrier within 30 days if the initial determination is modified or reversed.
(2)
This notice must contain adequate information to allow the intermediary or carrier to locate the claim file. This must include the name of the beneficiary, the Health Insurance Claim Number, the name of the provider, date of admission, and dates or services for which Medicare payment will not be made.
Notes, amendments, and revision history

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).

§478.36. Record of reconsideration.

42 C.F.R. § 478.36

(a)
QIO requirements. A QIO must maintain the record of its reconsideration until the later of the following:
(1)
Four years after the date on the notice of the QIO's reconsidered determination.
(2)
Completion of litigation and the passage of the time period for filing all appeals.
(b)
Contents of the record. The record of the reconsideration must include:
(1)
The initial determination.
(2)
The basis for the initial determination.
(3)
Documentation of the date of the receipt of the request for reconsideration.
(4)
The detailed basis for the reconsidered determination.
(5)
Evidence submitted by the parties.
(6)
A copy of the notice of the reconsidered determination that was provided to the parties.
(7)
Documentation of the delivery or mailing and, if appropriate, the receipt of the notice of the reconsidered determination by the parties.
(c)
Confidentiality. The record of a QIO reconsideration is subject to prohibitions against disclosure of information as specified in section 1160 of the Act.
Notes, amendments, and revision history

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).