GroundRules
42 CFR 478.15: QIO review of changes resulting from DRG validation.
Where this section sits in the code
- Title 42—Public Health
- CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
- SUBCHAPTER F—QUALITY IMPROVEMENT ORGANIZATIONS
- PART 478—RECONSIDERATIONS AND APPEALS
- Subpart B—Utilization and Quality Control Quality Improvement Organization (QIO) Reconsiderations and Appeals
(a) General rules. (1) A provider or practitioner dissatisfied with a change to the diagnostic or procedural coding information made by a QIO as a result of DRG validation under section 1866(a)(1)(F) of the Act is entitled to a review of that change if—
(i) The change caused an assignment of a different DRG; and
(ii) Resulted in a lower payment.
(2) A beneficiary may obtain a review of a QIO DRG coding change only if that change results in noncoverage of a furnished service.
(3) The individual who reviews changes in DRG procedural or diagnostic information must be a physician, and the individual who reviews changes in DRG coding must be qualified through training and experience with ICD-9-CM coding.
(b) Procedures. Procedures described in §§ 478.18 through 478.36 and 478.48(a) and (c) for a QIO reconsideration or reopening also apply to QIO review of a DRG coding change.
(c) Finality of review. No additional review or appeal for matters governed by paragraph (a) of this section is available.
Collected 2026-08-27T02:26:11Z. Source file · JSON