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. § 478.28

Qualifications of a reconsideration reviewer

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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.

[50 FR 15330, Apr. 17, 1985, as amended at 77 FR 68563, Nov. 15, 2012]
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). “42 C.F.R. §§ 478.28 , 478.30. Written notice of the reconsidered determination must be provided to the practitioner.”
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