View all text of Subjgrp 195 [§ 480.130 - § 480.145]

§ 480.133 - Disclosure of information about practitioners, reviewers and institutions.

(a) General requirements for disclosure. Except as specified in paragraph (b) of this section, the following provisions are required of the QIO.

(1) Disclosure to the identified individual or institution. A QIO must disclose, to particular practitioners, reviewers and institutions, information about themselves, upon request, and may disclose it to them without a request.

(2) Disclosure to others. (i) A QIO must disclose to an institution, upon request, information on a practitioner to the extent that the information displays practice or performance patterns of the practitioner in that institution.

(ii) In accordance with section 1160 of the Act, a QIO must disclose information that displays practice or performance patterns of a practitioner or institution in accordance with the procedures for disclosures specified in §§ 480.137 and 480.138 to—

(A) Federal and State agencies that are responsible for the investigation of fraud and abuse of the Medicare or Medicaid programs, and

(B) Federal and State agencies that are responsible for licensing and certification of practitioners and providers.

(iii) A QIO may disclose to any person, agency, or organization information on a particular practitioner or reviewer at the written request of or with the written consent of that practitioner or reviewer. The beneficiary of the information has the same redisclosure rights and responsibilities as the requesting or consenting practitioner or reviewer as provided under this Subpart B.

(iv) A QIO is not required to obtain the consent of a practitioner or provider prior to the release of information to a beneficiary in connection with an initial denial determination or in providing a beneficiary with the QIO's findings in response to a beneficiary complaint. Information that must be specified in a QIO's final decision in a complaint review is specified in §§ 476.130(d) and 476.140(b) of this subchapter.

(b) Exceptions. (1) If the request is in connection with an initial denial determination or a change resulting from a diagnostic related group (DRG) coding validation under part 476 of this subchapter, the QIO must provide only the information used to support that determination in accordance with the procedures for disclosure of information relating to determinations under § 478.24 of this subchapter.

(2) A QIO must disclose information regarding QIO deliberations only as specified in § 480.139(a).

(3) A QIO must disclose quality review study information only as specified in § 480.140.

[50 FR 15359, Apr. 17, 1885, as amended at 52 FR 37458, Oct. 7, 1987; 52 FR 47004, Dec. 11, 1987. Redesignated at 64 FR 66279, Nov. 24, 1999, as amended at 69 FR 49266, 29267, Aug. 11, 2004; 77 FR 68564, Nov. 15, 2012]