US · guidance
CMS Pub. 100-04, ch. 30, § 260.5.6
Make Determination and Notify Required Parties
No later than 72 hours after receipt of the request for an expedited determination, the QIO
must make its determination on whether the discharge is appropriate based on medical
necessity or other Medicare coverage policies.
Note: If the QIO does not receive supporting information from the provider, 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 QIO.
The QIO must 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. QIOs must also inform the beneficiary of the right to an expedited
reconsideration by the Qualified Independent Contractor (QIC) and how to request a
timely expedited reconsideration. The QIO will make its initial notification via telephone
and will follow up with a written determination letter.
History
(Rev. 2711, Issued: 05-24-13, Effective: 08-26-13, Implementation: 08-26-13)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
e7edabc15cd01ac859dceaf31369616afe61c1af93318b1198c77beef7bda485
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