Authority

1000 – Authority (Rev. 19, Issued: 05-01-15, Effective: 05-01-15, Implementation: 05-01-15) The Quality Improvement Organization (QIO) Program is authorized by Title XI Part B and Title XVIII of the Social Security Act (the Act). Citations in the Act indicate where the governing statutes for the QIO Program are codified in the United States Code (U.S.C.). Title XI Part B appears in the United States Code as 42 U.S.C. Sections1320c.- 1320c-8, and Title XVIII appears in the United States Code as 42 U.S.C Sections 1395- 1395ccc. The administrative entity responsible for the QIO Program is the Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services. Applicable regulatory provisions for the QIO Program are in Title 42 of the Code of Federal Regulations (CFR). The regulatory authorities and governing statutes for the QIO Program are as follows: Title and Part CFR Heading Relevant Sections Social Security Act and U.S.C Provisions Summary 42 CFR Part 405 Determinations, Redeterminations, Reconsiderations and Appeals under Original Medicare (Parts A and B) 405.900 to 990 Section 1869 (42 U.S.C. 1395ff) Regulations governing payment of Medicare claims including procedures related to initial determination reviews performed by QIOs (See: 405.204 and 405.900-990). 42 CFR Part 405 Expedited Determinations and Reconsiderations of Provider Service Terminations, and Procedures for and Inpatient Hospital Discharge Reviews 42 CFR 405.1200 to 1208 Section 1869(b)(1)(F) (42 U.S.C. 1395ff(b)(1)(F) Beneficiary rights to expedited determinations and hospital requests for expedited QIO review (See: 405.1200 -1208) 42 CFR Part 412 Prospective Payment Systems for Inpatient Hospital Services 412.42 to 48, 412.82 to 84, 412.508 Section1866(a) (1)(F) and (a)(3) (42 U.S.C. 1395cc) and 1154(a)(4) and (14) (42 U.S.C. 1320c-3(a)(4) and (14)) Requires hospitals to have agreements with QIOs for performance of Section 1154(a)(4) and (14) functions (See: Section 1866(a)(1)(F)). Requires hospitals to have agreements with QIOs and provides for QIO reviews of medically unnecessary inpatient hospital services (See: 412.42- Title and Part CFR Heading Relevant Sections Social Security Act and U.S.C Provisions Summary 48) and reviews of extended length of stay cases and high cost cases (See: 412.82- 84). Requires long- term care hospitals to have an agreement with an QIO for reviews of admissions and quality of care (See: 412.508) 42 CFR Part 422 (Subparts D and M) Medicare Advantage Program 422.153, 422.562, 422.564, and 422.622 Section 1852 and 1154(a)(4)(B), 1154(a)(14) (42 U.S.C. 1320c- 3(a)(14)) Requires Medicare Advantage (MA) Plans to conduct and document performance improvement and QIOs to collect, acquire, and furnish information about MA Plans to CMS as defined in 42 CFR 475 (See: 422.153). Requires MA Plans to establish complaint, grievance, and inpatient discharge procedures for review of its services by a QIO (See: 422.562, 422.564, and 422.622) 42 CFR Part 475 Quality Improvement Organizations 475.1 to 475.107 Sections 1151 – 1160 of the Social Security Act (42 U.S.C.1320c – 1320c-12) Specifies eligibility requirements to become a QIO selected by CMS and defines the QIO contract term 42 CFR Part 476 Quality Improvement Organization Review 476.1, 476.70 to 476.170 Section 1154 of the Social Security Act (42 U.S.C.1320c-3) Defines the QIO functions including the scope of case review 42 CFR Part 478 Reconsiderations and Appeals 478.10 to 478.48 Sections 1154 and 1155 of the Social Security Act (42 QIO procedures for reconsiderations or hearings related to its diagnostic coding or Title and Part CFR Heading Relevant Sections Social Security Act and U.S.C Provisions Summary U.S.C.1320c-3 and 1320c-4) payment determinations 42 CFR Part 480 Acquisition, Protection, and Disclosure of Quality Improvement Organization Information 480.101 to 480.145 Section 1160 of the Social Security Act (42 U.S.C.1320c-9) QIO confidentiality and disclosure responsibilities related to information it is authorized to collect, acquire, or generate 42 CFR Part 482 Conditions of Participation for Hospitals 482.30 and 482.21 Section 1861(e)(6) and 1861(k) of the Social Security Act (42 U.S.C. 1395x) Requires hospitals to have a utilization review plan, which it may meet by having reviews performed by a QIO (see: 482.30). Requires hospitals to conduct and document performance improvement projects and determine whether to participate in QIO cooperative projects (See: Section 482.21). 42 CFR Part 489 Provider Agreements and Supplier Approval 489.20(e)and 489.24(h) Sections 1866(a)(1)(F) and (a)(3) and 1867(d) of the Social Security Act (42 U.S.C. 1395cc and 42 U.S.C. 1320c- 3(a)(16)) Requires hospitals to maintain an agreement with QIOs to allow for review of the admissions, quality, appropriateness, and diagnostic information related to inpatient services (See: 489.20(e)). Provides for QIO reviews of hospital compliance with Emergency Medical Treatment and Labor Act (See: Section 489.24 (h)) 42 CFR Part 1004 Imposition of Sanctions on Health Care Practitioners and Providers of Health Care Services by a 1004.1 to 1004.140 Section 1156(a) of the Social Security Act (42 U.S.C. 1302 and 1320c-5) Review, notice, and reporting procedures for QIOs to recommend a sanction to the Office of the Inspector General Title and Part CFR Heading Relevant Sections Social Security Act and U.S.C Provisions Summary Quality Improvement Organization (OIG). QIOs are not responsible for the imposition of sanctions.