CMS Pub. 100-10, ch. 1, § 1015

Section 1152 of the Social Security Act and 42 CFR Part 475 provide the authority for

CMS to enter into contracts with entities to perform QIO functions. In awarding such

contracts, CMS complies with the Federal Acquisition Regulation (Title 48 CFR) unless

the Secretary determines that a specific provision is inconsistent with the purposes of

Title XI, Part B of the Social Security Act. In order to be awarded a QIO contract, an

entity must meet the following qualifying requirements:

• Have a governing body that includes at least one individual who is a representative of

healthcare providers and at least one individual who is a representative of consumers

(42 CFR 475.101(a))

• Demonstrate capability to meet the eligibility requirements and perform the activities

specified by CMS in the solicitation for award of a QIO contract (42 CFR

475.101(b)(1))

• Demonstrate the ability to perform case reviews as set forth in 42 CFR 475.102

and/or perform quality improvement as set forth in 42 CFR 475.103 (42 CFR

475.101(b)(2)

• Demonstrate the ability to actively engage beneficiaries, families, and consumers in

case reviews and/or quality improvement activities (42 CFR 475.101(c))

• Demonstrate the ability to perform QIO functions with objectivity and impartiality

and in a fair and neutral manner (42 CFR 475.1010(d))

• Demonstrate that it is not a healthcare facility, affiliate, or payer organization. QIOs

may not perform reviews of healthcare services other than the review of the quality of

care (42 CFR 475.105).

Pursuant to Section 1153(c) of the Social Security Act, the contract between CMS and a

QIO must provide the right for CMS to evaluate the quality and effectiveness of the QIO

in carrying out QIO functions. Further, CMS has the right to negotiate contractual

performance objectives and to provide specifications or modifications based on regional

or national norms for QIO contractors performing the quality improvement and case

review functions.

CMS has the responsibility to determine the efficient and effective administration of the

QIO Program, establish the program structure, determine the number of contracts and

limitations, define the service areas, solicit for QIO services, and negotiate awards. CMS

abides by the Federal Acquisition Regulation excepts when Section 1153(e) of the Social

Security Act permits an exception.