CFR > Title 42 - Public Health > CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES > SUBCHAPTER F—QUALITY IMPROVEMENT ORGANIZATIONS (parts 475 to 481) > PART 480—ACQUISITION, PROTECTION, AND DISCLOSURE OF QUALITY IMPROVEMENT ORGANIZATION REVIEW INFORMATION > SUBPART B—Utilization and Quality Control Quality Improvement Organizations (QIOs) (§480.101 to §480.143) > 480.137—Disclosure to Federal and State enforcement agencies responsible for the investigation or identification of fraud or abuse of the Medicare or Medicaid programs.

480.137—Disclosure to Federal and State enforcement agencies responsible for the investigation or identification of fraud or abuse of the Medicare or Medicaid programs.

(a) Required disclosure. Except as specified in §§ 480.139(a) and 480.140 relating to disclosure of QIO deliberations and quality review study information, the QIO must disclose confidential information relevant to an investigation of fraud or abuse of the Medicare or medicaid programs, including QIO medical necessity determinations and other information that includes patterns of the practice or performance of a practitioner or institution, when a written request is received from a State or Federal enforcement agency responsible for the investigation or identification of fraud or abuse of the Medicare or Medicaid programs that—
(1) Identifies the name and title of the individual initiating the request,
(2) Identifies the physician or institution about which information is requested, and
(3) States affirmatively that the institution or practitioner is currently under investigation for fraud or abuse of the Medicare or Medicaid programs and that the information is needed in furtherance of that investigation.
(b) Optional disclosure. The QIO may provide the information specified in paragraph (a) of this section to Federal or State fraud and abuse enforcement agencies responsible for the investigation or identification of fraud or abuse of the Medicare or Medicaid programs, without a request.
[50 FR 15358, Apr. 17, 1985, as amended at 52 FR 37458, Oct. 7, 1987. Redesignated at 64 FR 66279, Nov. 24, 1999, as amended at 69 FR 49267, Aug. 11, 2004]