QIO Reconsiderations - (Rev. 4, 07-18-03)

7420 - QIO Reconsiderations - (Rev. 4, 07-18-03) A. Qualifications of a QIO Reconsideration Reviewer A QIO reconsideration reviewer must meet the qualifications required of a QIO physician who makes an initial denial determination (See 42 CFR 478.28 and 42 CFR 476.98 for the eligibility requirements for and responsibilities of physician reviewers, including the obligation to consult with peers). The physician reviewer must also be a board-certified or board-eligible specialist in the same specialty as the physician whose services are being reviewed, and must be practicing in a setting similar to that of the physician whose services are under review, except:  If use of a like specialist in a similar setting is impractical for a particular case, use, if possible, a like specialist who practices in another setting.  If it is impractical for you to meet the conditions listed above, use a board- certified specialist (or board candidate) in the specialty that matches the services under review and who practices in a setting similar to that of the physician whose services are under review. If this is impractical, use a physician reviewer whose practice includes the services under review and whose practice is located in a setting similar to that of the physician whose services are under review. When this is not possible, document the reason(s) in the case file. Also, document the physician reviewer's qualifications in the case file (See §7430.F). The physician reviewer must not:  Be the reviewer who made the initial denial determination;  Have participated in developing or executing the beneficiary's treatment plan;  Be in practice with any physician involved in the care of the beneficiary;  Be a member of the beneficiary's family;  Be a governing body member, officer, partner, 5 percent or more owner, or managing employee in the health care facility where the services were or are to be furnished; or  Be a member of a reviewer's family, a spouse (other than one who is legally separated under a decree of divorce or separate maintenance), a child (including a legally adopted child), grandchild, parent, grandparent, or sibling. NOTE: A beneficiary's attending physician may not request a specific reviewer to conduct the reconsideration. B. Finality of a Reconsidered Determination Your reconsidered determination is final and binding upon all parties unless:  Reopened and revised by you, either on your own motion or at the request of any party within l year from the date of the reconsidered determination;  Reopened and revised by you after l year, but within 4 years, because: • You receive new and material evidence; • There is a clerical error in the statement of your reconsidered determination; • You erred in interpretation or application of Medicare coverage policy; or • There is an error apparent on the face of the evidence upon which your reconsidered determination was based.  Reopened and revised by you at any time if the reconsidered determination was obtained through fraud or an abusive practice (e.g., describing services in such a way that a wrong conclusion is reached); or  Reversed after appeals filed in accordance with §7440. The Administrative Law Judge (ALJ) or the Appeals Council, whichever made the final decision, may reopen and revise its decision in accordance with the procedures set forth in 42 CFR 405.750(b)(1) and (2) which covers reopening and re-reviews under subpart G of Part 405. A reconsidered determination, a review of a DRG change, or a decision of an ALJ or the Appeals Council may be reopened and reviewed at any time if the reconsideration determination, review, or decision was obtained through fraud or a similar abusive practice that does not support a formal finding of fraud.