Authority - (Rev. 4, 07-18-03)

7100 - Authority - (Rev. 4, 07-18-03) Deny claims in accordance with 42 CFR 476.83 when you determine that health care services furnished or proposed to be furnished to a beneficiary are non-covered because they are not medically necessary and reasonable (§1862(a)(1) of the Act) or constitute custodial care (§1862(a)(9) of the Act). In addition, QIOs may deny Part A claims when a hospital circumvents the Prospective Payment System (PPS) through unnecessary admissions or readmissions in accordance with §1886(f)(2) of the Act (Deny claims only as specified in §4255). If, as a result of DRG validation, you determine that the diagnosis and/or procedures billed by the hospital should be changed and the DRG is affected, change the DRG assignment in accordance with 42 CFR Part 476. Provide written notification of initial denial determinations and DRG assignment changes to all affected parties as specified in 42 CFR 476.94.