CFR

478.32—Time limits for issuance of the reconsidered determination.

(a) Beneficiaries. If a beneficiary files a timely request for reconsideration of an initial denial determination, the QIO must complete its reconsidered determination and send written notice to the beneficiary within the following time limits—

(1) Within three working days after the QIO receives the request for reconsideration if—

(i) The beneficiary is still an inpatient in a hospital for the stay in question when the QIO receives the request for reconsideration; or

(ii) The initial determination relates to institutional services for which admission to the institution is sought, the initial determination was made before the patient was admitted to the institution; and a request was submitted timely for an expedited reconsideration.

(2) Within 10 working days after the QIO receives the request for reconsideration if the beneficiary is still an inpatient in a SNF for the stay in question when the QIO receives the request for reconsideration.

(3) Within 30 working days after the QIO receives the request for reconsideration if—

(i) The initial determination concerns ambulatory or noninstitutional services;

(ii) The beneficiary is no longer an inpatient in a hospital or SNF for the stay in question; or

(iii) The beneficiary does not submit a request for expedited reconsideration timely.

(b) Providers or practitioners. If the provider or practitioner files a request for reconsideration of an initial determination, the QIO must complete its reconsidered determination and send written notice to the provider or practitioner within 30 working days.

Tips