{"data":{"id":"us/42-cfr-476.96","jurisdiction":"us","citation":"42 CFR 476.96","heading":"Review period and reopening of initial denial determinations and changes as a result of DRG validations.","body":"(a) General timeframe. A QIO or its subcontractor—\n(1) Within one year of the date of the claim containing the service in question, may review and deny payment; and\n(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.\n(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.\n(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—\n(i) Additional information is received on the patient's condition;\n(ii) Reviewer error occurred in interpretation or application of Medicare coverage policy or review criteria;\n(iii) There is an error apparent on the face of the evidence upon which the initial denial or DRG validation was based; or\n(iv) There is a clerical error in the statement of the initial denial determination or change as a result of a DRG validation.\n(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.\n(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.","path":["Title 42—Public Health","CHAPTER IV—CENTERS FOR MEDICARE \u0026 MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES","SUBCHAPTER F—QUALITY IMPROVEMENT ORGANIZATIONS","PART 476—QUALITY IMPROVEMENT ORGANIZATION REVIEW","Subpart C—Review Responsibilities of Quality Improvement Organizations (QIOs)"],"source_url":"https://www.ecfr.gov/api/versioner/v1/full/2026-08-25/title-42.xml","current_through":"2026-08-25","vintage":"","retrieved_at":"2026-08-27T02:26:11Z","sha256":"3db509424f84e9e89fdf51b2a626543d500d5c0ed64059ece3538ca8e73ece6b","source_id":"us-cfr","stale":true,"prev":"us/42-cfr-476.94","next":"us/42-cfr-476.98"},"notice":"GroundRules: Original legal text. Not legal advice."}