US · guidance
CMS Pub. 100-10, ch. 1, § 1005
QIO Program Purpose
CMS contracts with QIOs to perform core functions that include case review and quality
improvement. Sections 1152 and 1153(a), (b), (c), and (e) of the Social Security Act and
42 CFR Part 475.101 through 475.103 define requirements for an entity to be awarded a
contract to perform QIO functions.
The case review functions of a QIO include review of healthcare services and items for
which payment is made under Medicare Parts A, B, C, or D to determine whether
services or items are reasonable, medically necessary, and allowable, meet
professionally recognized standards of care, or in the case of inpatient care, could be
provided more economically on an outpatient basis or in an inpatient facility of a
different type. Generally, case reviews must be performed by a healthcare practitioner in
the same professional field as the healthcare practitioner who ordered or furnished the
services under review. The QIO must perform case review functions as outlined in 42
CFR Part 476 and as defined in its contract with CMS. Other chapters of this manual
provide more specific guidance on the various case review functions.
Quality improvement functions may include technical assistance, data analysis, and
stakeholder engagement activities that promote evidence-based healthcare practice and
patient-centered care principles to improve healthcare quality of care, improve outcomes
to beneficiaries, and lower costs. The QIO must perform quality improvement functions
consistent with the terms of its contract with CMS. Quality improvement functions may
include, but are not limited to, the following:
• Engaging patients, families, and care-givers with the goal of increasing patient
knowledge, skill, and confidence to take an active role in managing their health and
healthcare
• Technical assistance related to CMS quality measures across settings to help
providers and practitioners meet standards
An activity designed to serve as a catalyst and support for quality improvements that may
relate to safety, healthcare, health, and value, and involve providers, practitioners,
beneficiaries, and/or communities
History
(Rev. 19, Issued: 05-01-15, Effective: 05-01-15, Implementation: 05-01-15)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
55b5a97079ecbdf6938190c8ddb9e7148706936ee665f1007ddf54e91378a94c
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