US · guidance
CMS Pub. 100-08, ch. 7, § 7.1.2.7.2
QA for Development of the Prioritized Problem List
The MAC shall list the data and the metrics used to determine and verify each identified
prioritized problem. That is, each identified prioritized problem shall have an
explanation of current data and other information used to support the decisions to include
the problem and assign its priority. The QA process shall ensure that MR activities and
improper payment interventions are not dedicated to problems that are consistently
overturned on appeal, based on outdated data analysis, or the focus of other operational
areas of the MAC with similar goals.
The QA shall be performed for each intervention that checks for effectiveness and
progress towards the specified goal. The QA component shall include a projected goal, a
timeline to achieve the goal, and an element to assess effectiveness of the intervention
and progress towards the stated goal. The QA component shall include a determination
of whether the problem has been resolved or partially met, or whether a more progressive
course of action is required. The MAC shall evaluate the effectiveness of edits and the
priority status of the problem. An effective QA process shall also include periodic
meetings with other operational areas, such as POE.
History
(Rev. 599, Issued: 06-26-15, Effective: 12-07-15, Implementation: 12-07-15)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
9f1d77638f114e3abeaea274fdd861a85b592306e566f3c6a400cfd9cd1e45c0
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