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

These regulations implement that portion of the Peer Review Improvement Act of 1982 that provides for reconsiderations and appeals of Utilization and Quality Control Peer Review Organization (PRO) initial determinations. We are establishing procedures for a PRO to reconsider both its initial denial determinations regarding the medical necessity, reasonableness and appropriateness of health care services furnished or proposed to be furnished to a Medicare beneficiary in a health care institution and the application of the limitation of liability provision. We are also including in this final rule procedures for administrative appeals to the Department following a PRO reconsidered determination and judicial review following administrative appeals. In addition, these regulations establish procedures for review of a PRO change in the diagnostic and procedural coding information that results in assignment of a discharge to a different diagnosis related group (DRG). This pertains to the review of claims for services furnished in hospitals reimbursed by Medicare under the prospective payment system.