US · guidance
CMS Pub. 100-08, ch. 4, § 4.9.4.2
UPICs and QIOs
Communication with the QIO is essential to discuss the potential impact of efforts to
prevent abuse, as well as ensure efforts are made to improve quality of care and access
to such care.
If potential patient harm is discovered during the course of screening a lead or through
the investigation process, the UPIC shall refer those instances to the QIO, state medical
board, or state licensing agency. In addition to making the appropriate referrals, the
UPIC shall notify the BFL, with a copy to the COR, within two (2) business days once
the potential patient harm issue is discovered.
If the UPIC refers a provider to the State licensing agency or medical society (i.e., those
referrals that need immediate response from the State licensing agency), the UPIC shall
also send a copy of the referral to the QIO.
If a claim has been reviewed by the QIO, the decision made is final and binding on
CMS, and the specific decision rendered by the QIO shall not be overturned by the
UPIC.
History
(Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
43ba5dd112f5e1caf1691b4613ed9b0dd24285e8bfb6e11fe344cdc39ac72774
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