Source: https://www.ecfr.gov/cgi-bin/text-idx?node=sp42.2.405.j&rgn=div6
Timestamp: 2019-12-11 23:25:11
Document Index: 613551968

Matched Legal Cases: ['art 405', '§405', '§405', '§405', '§405', '§405', '§405', '§405', '§405', '§405', '§405', '§405', '§405', '§405', '§476', '§405', '§405', '§405', '§405', '§405', '§405', '§405', '§405', '§405', '§405', '§405']

Title 42 → Chapter IV → Subchapter B → Part 405 → Subpart J
§405.1202 Expedited determination procedures.
§405.1204 Expedited reconsiderations.
§405.1205 Notifying beneficiaries of hospital discharge appeal rights.
§405.1206 Expedited determination procedures for inpatient hospital care.
§405.1208 Hospital requests expedited QIO review.
Source: 69 FR 69624, Nov. 26, 2004, unless otherwise noted.
(2) The QIO determines whether the provider delivered valid notice of the termination decision consistent with §405.1200(b) and paragraph (f) of this section.
(2) Upon notification by the QIO of the request for an expedited determination, the provider must supply all information that the QIO needs to make its expedited determination, including a copy of the notices required under §405.1200(b) and under paragraph (f)(1) of this section. The provider must furnish this information as soon as possible, but no later than by close of business of the day the QIO notifies the provider of the request for an expedited determination. At the discretion of the QIO, the provider may make the information available by phone or in writing (with a written record of any information not transmitted initially in writing).
(5) Unless the beneficiary requests an extension in accordance with paragraph (c)(6) of this section, if the QIC does not issue a decision within 72 hours of receipt of the request, the QIC must notify the beneficiary of his or her right to have the case escalated to OMHA for an ALJ hearing in accordance with subpart I of this part, if the amount remaining in controversy after the QIO determination meets the requirements for an ALJ hearing under §405.1006.
(a) Applicability and scope. (1) For purposes of §§405.1204, 405.1205, 405.1206, and 405.1208, the term “hospital” is defined as any facility providing care at the inpatient hospital level, whether that care is short term or long term, acute or non acute, paid through a prospective payment system or other reimbursement basis, limited to specialty care or providing a broader spectrum of services. This definition includes critical access hospitals.
(2) For purposes of §§405.1204, 405.1205, 405.1206, and 405.1208, a discharge is a formal release of a beneficiary from an inpatient hospital.
(ii) The beneficiary's right to request an expedited determination of the discharge decision including a description of the process under §405.1206, and the availability of other appeals processes if the beneficiary fails to meet the deadline for an expedited determination.
(iv) A beneficiary's right to receive additional detailed information in accordance with §405.1206(e).
(2) Follow up notification is not required if the notice required under §405.1205(b) is delivered within 2 calendar days of discharge.
[71 FR 68720, Nov. 27, 2006]
(b) Requesting an expedited determination. (1) A beneficiary who wishes to exercise the right to an expedited determination must submit a request to the QIO that has an agreement with the hospital as specified in §476.78 of this chapter. The request must be made no later than the day of discharge and may be in writing or by telephone.
(2) The QIO determines whether the hospital delivered valid notice consistent with §405.1205(b)(3).
(iv) Information about the beneficiary's right to a reconsideration of the QIO's determination as set forth in §405.1204, including how to request a reconsideration and the time period for doing so.
(2) Upon notification by the QIO of the request for an expedited determination, the hospital must supply all information that the QIO needs to make its expedited determination, including a copy of the notices required as specified in §405.1205 (b) and (c) and paragraph (e)(1) of this section. The hospital must furnish this information as soon as possible, but no later than by noon of the day after the QIO notifies the hospital of the request for an expedited determination. At the discretion of the QIO, the hospital must make the information available by phone or in writing (with a written record of any information not transmitted initially in writing).
(4) Hospital requests an expedited review. When the hospital requests a review in accordance with §405.1208, and the QIO concurs with the hospital's discharge determination, a hospital may not charge the beneficiary until the date specified by the QIO.
(1) Right to request a reconsideration. If the beneficiary is still an inpatient in the hospital and is dissatisfied with the determination, he or she may request a reconsideration according to the procedures described in §405.1204.
[71 FR 68721, Nov. 27, 2006]
(1) When a beneficiary remains in the hospital. If the beneficiary is still an inpatient in the hospital and is dissatisfied with this determination, he or she may request a reconsideration according to the procedures described in §405.1204. The procedures described in §405.1204 will apply to reconsiderations requested under this section. If the beneficiary does not make a request in accordance with §405.1204(b)(1), the timeframes described in §405.1204(c)(3), the escalation procedures described in §405.1204(c)(5), and the coverage rule described in §405.1204(f) will not apply.