C.F.R. » Title 42 » 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

42 C.F.R. § 478.24

Opportunity for a party to obtain and submit information

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(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 of Decisions
Cited in 1 case, 2011–2011 · leading case: Wittenberg v. Oklahoma Health Care Auth., 781 F. Supp. 2d 1221 (N.D. Okla. 2011).
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Wittenberg v. Oklahoma Health Care Auth., 781 F. Supp. 2d 1221 (N.D. Okla. 2011). · cites it 2× “42 C.F.R. §§ 478.24 (a), 478.24(c). The reconsideration must be completed by an individual other than the one who made the initial denial determination, and may be based on the information that led to the initial determination, new information found in medical records, or…”
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