CMS Pub. 100-10, ch. 9, § 9130

If the Regional Office DSC finds that the case involves a possible violation of §1867 and

this determination rests wholly or in part on the clinical aspects of the case, the DSC must

consult with the QIO before determining whether the hospital has violated EMTALA,

unless delaying to obtain a QIO review would jeopardize the health or safety of

individuals. Clinical aspects of the case may include questions such as whether the

individual had an emergency medical condition, whether there was an appropriate

medical screening examination, whether a hospital had the capability to provide

stabilizing treatment, whether an individual’s emergency medical condition was stabilized,

whether a transfer was appropriate, whether a recipient hospital had the required

capability and capacity to provide stabilizing treatment, and any other questions as

necessary.

In reviewing cases, the QIO physician reviewer should consider information that the

treating physician:

1. Had, could have had, and should have had available to him/her at the time of the

individual's visit; and

2. Could have discovered reasonably and which was necessary to adequately care for

the individual (e.g., the physician should have conducted an adequate history

interview) at the time of the individual’s visit.

The Regional Office DSC may also require the QIO to participate in an informal

discussion that the Regional Office sets up with the affected physician/hospital to discuss

the case.

NOTE: CMS has the authority and responsibility to determine whether the law has been

violated. The QIO physician reviewer MUST NOT state an opinion about whether a

violation has occurred.