42 CFR § 476.94 - Notice of QIO initial denial determination and changes as a result of a DRG validation.
(a) Notice of initial denial determination -
(iii) The facility; and
(iv) The Medicare administrative contractor, fiscal intermediary, or carrier.
(2) Timing of the notice. The notice must be delivered to beneficiaries in the facility or mailed to those no longer in the facility, within the following time periods -
(ii) For continued stay (e.g., outliers in facilities under a prospective payment system), by the first working day after the initial denial determination if the beneficiary is still in the facility, and within 3 working days if the beneficiary has been discharged;
(iii) For preprocedure review, before the procedure is performed;
(iv) For preadmission review, before admission;
(v) If identification as a Medicare program patient has been delayed, within three working days of identification;
(vii) For post-procedure review, within 3 working days of the initial denial determination.
(b) Notice of changes as a result of a DRG validation. The QIO must notify the provider and practitioner of changes to procedural and diagnostic information that result in a change of DRG assignment, within 30 days of the QIO's decision.
(c) Content of the notice. The notice must be understandable and written in plain English and must contain -
(2) For day outliers in hospitals, the date on which the stay or services in the facility will not be approved as being reasonable and medically necessary or appropriate to the patients' health care needs;
(i) Review of a change resulting from DRG validation; or
(ii) Reconsideration of the initial denial determination;
(4) The locations for filing a request for reconsideration or review and the time period within which a request must be filed;
(d) Notice to payers. The QIO must provide prompt written notice of an initial denial determination or changes as a result of a DRG validation to the Medicare administrative contractor, fiscal intermediary, or carrier within the same time periods as the notices to the other parties.
(e) Record of initial denial determination and changes as a result of a DRG validation.
(2) The documentary record must include -