Code of Federal Regulations Title 42. Public Health § 42.476.96 Review period and reopening of initial denial determinations and changes as a result of DRG validations

(1) Within one year of the date of the claim containing the service in question, may review and deny payment;  and

(2) Within one year of the date of its decision, may reopen an initial denial determination or a change as a result of a DRG validation.

(1) An initial denial determination or change as a result of a DRG validation may be made after one year but within four years of the date of the claim containing the service in question, if CMS approves.

(2) A reopening of an initial denial determination or change as a result of a DRG validation may be made after one year but within four years of the date of the QIO's decision if—

(1) A QIO or its subcontractor may review and deny payment anytime there is a finding that the claim for service involves fraud or a similar abusive practice that does not support a finding of fraud.

(2) An initial denial determination or change as a result of a DRG validation may be reopened and revised anytime there is a finding that it was obtained through fraud or a similar abusive practice that does not support a finding of fraud.