CMS Pub. 100-08, ch. 6, § 6.6

The MACs shall only refer Quality of (Health) Care Concerns to the QIOs. A Quality of

(Health) Care Concern is defined as “a concern that care provided did not meet a

professionally recognized standard of health care.” The Contractor shall follow the

referral process as agreed upon in the QIO-MAC Joint Operating Agreement. The QIOs

will retain their responsibility for performing expedited determinations, Hospital-Issued

Notices of Non-Coverage (HINN) reviews, quality reviews, transfer reviews, readmission

reviews and, provider-requested higher-weighted DRG reviews.

The Circumvention of PPS will continue to be reported to your UPIC. The quality

initiatives associated with payment for performance are now the reporting source for

Readmission Reviews and Transfer Review data to the QIOs. Non-covered

benefits/services are not to be reported to the QIO.

All initial payment determinations and claim adjustments are required to be performed by

the MAC.

All MACs are to turn off all automated edits/processes that generate a referral to the

QIOs prior to a medical record review of the claim. Referrals to the QIO shall be limited

to Quality of Health Care issues as defined above and shall result from a clinician’s

medical record review of a provider’s medical documentation.

If during the medical record review process, “a concern that care provided did not meet a

professionally recognized standard of health care,” the MAC shall issue a payment

determination and/or adjustment for the claim, complete the QIO referral form, and

forward the completed referral form and file(s) to the QIO. If the referral form is not

complete, the QIO will return the file to the MAC and request that the MAC provide the

missing information prior to the QIO performing a review.

A non-covered service and/or procedure shall not be automatically referred to the QIO.

The MAC shall make the initial payment determination and/or claim adjustment for a

non-covered service or procedure in accordance with the Medicare IOM 100-04, Claims

Processing Manual and IOM 100-02, Benefit Policy Manual.

If during the medical record review process, “a concern that care provided did not meet a

professionally recognized standard of health care,” such as a medically unnecessary

procedure, the claim shall be referred to the QIO for quality review after payment

determination and/or claim adjustment is made.

The MACs shall not instruct providers, suppliers, or beneficiaries to refer payment issues

to the QIO. If the provider or supplier does not agree with the payment and/or claim

adjustment decision, the MAC shall communicate their options to follow the current

process in IOM 100-08, requesting a reopening or an appeal. If the beneficiary disagrees

with the payment decision and makes a request for re-evaluation/redetermination, this

will be considered a demand bill and is the responsibility of the MAC.