US · guidance
CMS Pub. 100-04, ch. 30, § 240.5
Effect of the QIO Review
The QIO will send the beneficiary a formal determination of the medical necessity and
appropriateness of the hospitalization determination is binding on the beneficiary, the
physician, and hospital except in the following circumstances:
Right to pursue a reconsideration. If the beneficiary is still an inpatient in the hospital
and is dissatisfied with the determination, he or she may request a reconsideration
according to the procedures described in §405.1204 (See Section 300 of this chapter.)
Right to pursue the general claims appeal process. If the beneficiary is no longer an
inpatient in the hospital, the determination is subject to the general claims appeal process
(See Chapter 29 of this manual.)
History
(Rev. 1257, Issued: 05-25-07; Effective: 07-01-07; Implementation: 07-02-07)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
33d7dade7304ca9b9fabc5c918d63c6e5b60473576b8e802a80f02eac5b79795
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