Statutory and Regulatory Requirements - (Rev. 4, 07-18-03)

7400 - Statutory and Regulatory Requirements - (Rev. 4, 07-18-03) Sections 1862 and 1155 of the Social Security Act (the Act) and 42 CFR Part 478 set forth the appeals requirements applicable to your Part A and Part B initial denial determinations by providing that a beneficiary, practitioner, or provider dissatisfied with your initial denial determination involving medical necessity, reasonableness of services, or appropriateness of setting is entitled to a reconsideration. A provider dissatisfied with your initial denial determination involving circumvention of PPS (§1886(f)(2) of the Act) is also entitled to a reconsideration. Section 1879 of the Act (Limitation on Liability) and 42 CFR Part 405 Subpart G provide that the beneficiary who has been found liable may obtain a reconsideration and appeal of a Part A QIO determination. §1879(a) of the Act and 42 CFR Part 405 Subpart H provide that the beneficiary who has been found liable may obtain a reconsideration and appeal of a Part B QIO determination. If the provider or practitioner has been found liable and the beneficiary has been found not liable, or if the beneficiary has been found liable and does not pursue a reconsideration on the issue of knowledge, the provider or practitioner may obtain a reconsideration on the issue that they did not know and could not be expected to have known the services denied were not covered under Medicare Part A and/or B. The criteria for determining beneficiary and provider/practitioner knowledge are found in 42 CFR 411.404 and 411.406.