US · guidance
CMS Pub. 100-10, ch. 9, § 9220
Evaluation Report Requirements
The QIO written report should contain:
1. The physician review findings as to the medical appropriateness, necessity, and
quality of the services provided;
2. The basis for the determination; and
3. When applicable, any advice on additional development needed to properly
adjudicate any remaining issues.
The report must be signed by the QIO authorized representative (e.g., the Executive
Director or Medical Director) and include the titles and qualifications of the physician
reviewer(s).
When the QIO forwards the report, the QIO should include with it all materials that CMS
or the outside agency provided to the QIO. After reviewing the cases included in the QIO
report, the QIO can initiate a sanction investigation and recommendation if the issues
found are within the QIO area of responsibility. Otherwise, the QIO involvement with the
particular case usually ends with the evaluation report submitted to CMS.
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
9f546579826bfac04336d1249f3323f93fdbbd8e8bd433ba7d7bb9869904108d
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