US · guidance
CMS Pub. 100-04, ch. 30, § 200.5.6
Make Determination and Notify Required Parties
No later than one calendar day after it receives all requested information, the BFCC-QIO
must make its determination on whether the discharge is appropriate based on medical
necessity or other Medicare coverage policies.
The BFCC-QIO must perform the following actions.
1. Notify the beneficiary, the beneficiary’s physician, and the provider of services of
its determination. This notification must include the rationale for the
determination and an explanation of Medicare payment consequences and
beneficiary liability.
2. Inform the beneficiary of the right to an expedited reconsideration by the BFCC-QIO and how to request a timely expedited reconsideration.
3. Make its initial notification via telephone and follow up with a written
determination letter.
NOTE:
If the BFCC-QIO does not receive supporting information from the hospital, it may make
its determination based on the evidence at hand, or defer a decision until it receives the
necessary information. If this delay results in continued services for the beneficiary, the
provider may be held financially liable for these services as determined by the BFCC-QIO.
History
(Rev. 11210; Issued: 01-21-2022; Effective: 04-21-2022; Implementation: 04-21- 2022)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
572a54f807d2ad85d7d448f1ce6a67530d4fb391e5380653e7ba429d6d3dc8c9
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