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Review period and reopening of initial denial determinations and changes as a result of DRG validations.
42 CFR § 476.96
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42 CFR § 476.96
42 CFR § 476.96
Review period and reopening of initial denial determinations and changes as a result of DRG validations.
(a)
General timeframe. A QIO or its subcontractor—
(1)
Within one year of the date of the claim containing the service in question, may review and deny payment; and
(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.
(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.
(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—
(i)
Additional information is received on the patient's condition;
(ii)
Reviewer error occurred in interpretation or application of Medicare coverage policy or review criteria;
(iii)
There is an error apparent on the face of the evidence upon which the initial denial or DRG validation was based; or
(iv)
There is a clerical error in the statement of the initial denial determination or change as a result of a DRG validation.
(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.
(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.
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