Medicare program, utilization and quality control peer review organization (PRO) reconsiderations and appeals--HCFA. Proposed rule.

Abstract

This proposed rule would implement that portion of the Peer Review Improvement Act of 1982 (Title I, Subtitle C of the Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248) addressing reconsiderations and appeals of PRO denial determinations. The proposed regulations would establish procedures for (1) a PRO to reconsider both its denial determinations regarding the medical necessity, reasonableness and appropriateness of health care service furnished or proposed to be furnished to a Medicare beneficiary in a health care institution and the application of the limitation of liability provision; (2) administrative appeals to the Department following a PRO reconsidered determination; and (3) judicial review following an administrative hearing.