US · guidance
CMS Pub. 100-10, ch. 9, § 9200
Scope of QIO Fraud and Abuse Review Activities
In accordance with the QIO contract and 42 CFR Part 476, the QIO must make available
the medical expertise necessary to conduct reviews and render quality of care and medical
necessity decisions in cases CMS refers to the QIO. The referrals may involve Medicare
services in settings other than those normally covered by the QIO reviews.
If the QIO identifies possible practice or performance patterns of fraud or abuse situations
during its regular case review activity, regardless of whether these situations/issues are
within the QIO area of responsibility, the QIO should notify the Federal or State fraud and
abuse enforcement agency that has jurisdiction, or in the case of a provider, the
appropriate intermediary component pursuant to 42 CFR §480.133. See also 42 CFR
§480.137.
History
(Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
f09271b8a9bf5349e7af71783066ed7993f39b928d4435839be3daecd8c77226
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