US · guidance
CMS Pub. 100-10, ch. 4, § 4735
Timing Requirements for Performance Improvement Activities -
Request an action plan from a provider within 30 calendar days of the date you have
determined an action plan is required. You may delay this request for a short period with
good reason. However, it is expected that delays will be rare. Allow 30 calendar days
for the provider to develop an action plan.
Be familiar with timeframes in which performance can reasonably be expected to
improve. Use your assessment of the nature and magnitude of the pattern of concerns
and your knowledge and experience of the nature of institutional change in general and
with specific providers to set appropriate timeframes for improvement. Do not allow
providers or practitioners unreasonable periods of delay in developing or implementing
action plans or in proceeding with other improvement activities (e.g., a mini-residency).
Interpret unreasonable delays as refusal to cooperate and proceed accordingly.
Exhibit 4-1 - Standard Mandatory Case Review Process -
S TANDARD M ANDATORY C ASE R EVIEW P ROCESS
Concern?
End
QIO receives
case for review
QIO requests
medical records
from provider
QIO closes
case and logs
decision in
SDPS
QIO requires
addit. medical
record info.
QIO reviews
medical records
30 C-Days*
Yes
No
QIO sends
concern to
provider/
practitioner
QIO refers
case to approp.
agency
QIO reviews
response
Provider/
practitioner
responds
No action
necessary
Initial Denial of
Payment
(Utilization)
Quality
Determination
(Quality)
QIO notifies
provider/
practitioner
No
QIO receives
request for
reconsideration
QIO
reconsiders
case
QIO notifies
provid./practit./
intermed./bene.
QIO prepares
Acknowledg.
Letter
ALJ reviews
case
ALJ notifies
CMS and QIO
of decision
QIO receives
request for re-review
QIO re-reviews
case
Provid./practit./
bene. request
reconsid.
QIO notifies
provid./practit./
intermed./bene.
QIO notifies
provid./practit./
intermed./bene.
Yes 30 C-Days*
Yes
Notify provider/
practitioner
Provider/
practitioner
request re-review
Yes
No
30 C-Days**
Notify provider/
practitioner
No
20 C-Days*
Concern
Confirmed?
End
End
Accept
Decision? End
Reverse
Decision?
Req. ALJ
Hearing?
QIO prepares
file for ALJ
Retrospective Review
*C-Days = calendar days **W-Days = working days
Re-Openings Review
15 C-Days*
QIO logs
decision on
SDPS
QIO logs
decision on
SDPS
QIO makes
decision
QIO logs
decision on
SDPS
End
End
Yes
30 C-Days*
QIO logs
decision on
SDPS
60 C-Days*
QIO logs
decision on
SDPS
QIO logs
decision on
SDPS
No
30 W-Days*
60 C-Days*
30 W-Days**
(Rev. 2, 07-11-03)s_Exhibit_4_1A
Exhibit 4-1A - Standard Mandatory Case Review Process Timeframes - (Rev. 2, 07-11-03)
STANDARD MANDATORY CASE REVIEW PROCESS TIMEFRAMES
Re-Openings ReviewRetrospective Review
Timeframes:
60 Calendar Days: Unquestioned Case
90 Calendar Days: Questioned Case (for DRG/validation)
100 Calendar Days: Questioned Case (for Quality of Care)
Timeframes:
30 Calendar Days: Unquestioned Case
50 Calendar Days: Questioned Case (for DRG/validation)
60 Calendar Days: Questioned Case (for Quality of Care)
(ADD 15 CALENDAR DAYS WHEN APPLICABLE)
(FROM RECEIPT OF REQUEST)(FROM RECEIPT OF MEDICAL RECORDS)
History
(Rev. 2, 07-11-03)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
e10898369a62b591d3a6f66a68f2c4387f81b8630e7b908acca9870d596e853e
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