Quality Improvement Organization Review

Definitions.

This section provides definitions for terms used in the Quality Improvement Organization review process, including beneficiary complaints, medical necessity, and payment-related reviews.

Use of norms and criteria.

This provision mandates that Quality Improvement Organizations (QIOs) establish and apply specific norms and criteria to evaluate the medical necessity and appropriateness of inpatient facility stays and procedures.

Involvement of health care practitioners other than physicians.

This provision requires QIOs to consult with and involve non-physician health care practitioners in the development of review criteria and the conduct of peer reviews for services provided by their peers.

Coordination of activities.

This provision requires QIOs to coordinate their review activities and information exchanges with Medicare administrative contractors and other review organizations to ensure efficient and economical review.

Use of immediate advocacy to resolve oral beneficiary complaints.

This provision establishes the immediate advocacy process for resolving oral beneficiary complaints, including requirements for consent, confidentiality, and discontinuation.

Submission of written beneficiary complaints.

This provision outlines the requirements and timeframes for submitting written complaints to a QIO regarding the quality of health care received by a Medicare beneficiary.

Beneficiary complaint review procedures.

This provision details the procedures for QIO review of beneficiary complaints, including medical information requests, interim determinations, and final notifications.

Beneficiary complaint reconsideration procedures.

This provision defines the process for requesting and conducting a reconsideration of a QIO's final initial determination regarding a beneficiary complaint.

Abandoned complaints and reopening rights.

This provision specifies the conditions under which a QIO may determine a complaint has been abandoned and the procedures for reopening a complaint review.

General quality of care review procedures.

This provision outlines the procedures for Quality Improvement Organizations (QIOs) to conduct quality of care reviews, including data analysis, medical information requests, and initial determinations.

General quality of care reconsideration procedures.

This provision establishes the process for providers to request a reconsideration of a QIO's initial quality of care determination, including timelines and submission of evidence.

Statutory bases and applicability.

This provision identifies the statutory authority for QIO review activities and defines the scope of applicability for the regulations in this subpart.

QIO review requirements.

This provision details the specific review functions of QIOs, including medical necessity, quality of care, DRG validation, and admission/discharge appropriateness.

Notification of QIO designation and implementation of review.

This provision mandates the notification process for QIO contract awards and the implementation of review activities within health care facilities.

General requirements for the assumption of review.

This provision sets forth the requirements for QIOs to assume review responsibilities, including maintenance of review plans and subcontracting limitations.

Cooperation with health care facilities.

This provision requires QIOs to make a good faith effort to discuss administrative and review procedures with health care facilities before implementation.

Responsibilities of providers and practitioners.

This provision mandates that hospitals cooperate with Quality Improvement Organizations (QIOs) by providing requested patient data, maintaining written agreements, and adhering to electronic submission requirements or approved waiver processes for record transmission.

Coordination with Medicare administrative contractors, fiscal intermediaries, and carriers

This provision establishes the requirements for Quality Improvement Organizations to maintain written agreements with Medicare administrative contractors to coordinate review functions and payment determinations.

Continuation of functions not assumed by QIOs.

This provision clarifies that duties not assumed by a QIO under its contract must be performed as otherwise provided under the Act or regulations.

Initial denial determinations.

This provision defines an initial denial determination by a QIO as a finding that services are not medically necessary, reasonable, or at the appropriate level of care.

Changes as a result of DRG validation.

This provision allows providers to obtain a QIO review for changes in diagnostic and procedural coding that result in a change in DRG assignment.

Conclusive effect of QIO initial denial determinations and changes as a result of DRG validations.

This provision establishes that QIO initial denial determinations and DRG validation changes are final and binding unless reconsidered or revised through established procedures.

Correlation of Title XI functions with Title XVIII functions.

This provision outlines how QIO review activities fulfill utilization review requirements and how QIO determinations are conclusive for Medicare payment purposes.

Examination of the operations and records of health care facilities and practitioners.

This provision mandates that facilities claiming Medicare payment must permit QIOs to examine operations and records pertinent to Medicare beneficiaries.

Lack of cooperation by a provider or practitioner.

This provision outlines the consequences for providers who fail to cooperate with QIO review, including potential reporting to the HHS Inspector General and claim denials.

Opportunity to discuss proposed initial denial determination and changes as a result of a DRG validation.

This provision requires QIOs to notify providers and attending physicians of proposed denials or DRG changes and provide an opportunity to discuss the matter before a final determination.

Notice of QIO initial denial determination and changes as a result of a DRG validation.

This provision mandates the timing, content, and delivery requirements for Quality Improvement Organization (QIO) notices regarding initial denial determinations and DRG validation changes.

Review period and reopening of initial denial determinations and changes as a result of DRG validations.

This provision establishes the timeframes for QIO review, denial of payment, and the reopening of determinations, including exceptions for fraud and abuse.

Reviewer qualifications and participation.

This provision sets the professional qualifications for QIO reviewers and mandates conflict-of-interest exclusions for individuals involved in the care or governance of the facility under review.