QIO Eligibility

1015 - QIO Eligibility (Rev. 19, Issued: 05-01-15, Effective: 05-01-15, Implementation: 05-01-15) Section 1152 of the Social Security Act and 42 CFR Part 475 provide the authority for CMS to enter into contracts with entities to perform QIO functions. In awarding such contracts, CMS complies with the Federal Acquisition Regulation (Title 48 CFR) unless the Secretary determines that a specific provision is inconsistent with the purposes of Title XI, Part B of the Social Security Act. In order to be awarded a QIO contract, an entity must meet the following qualifying requirements: • Have a governing body that includes at least one individual who is a representative of healthcare providers and at least one individual who is a representative of consumers (42 CFR 475.101(a)) • Demonstrate capability to meet the eligibility requirements and perform the activities specified by CMS in the solicitation for award of a QIO contract (42 CFR 475.101(b)(1)) • Demonstrate the ability to perform case reviews as set forth in 42 CFR 475.102 and/or perform quality improvement as set forth in 42 CFR 475.103 (42 CFR 475.101(b)(2) • Demonstrate the ability to actively engage beneficiaries, families, and consumers in case reviews and/or quality improvement activities (42 CFR 475.101(c)) • Demonstrate the ability to perform QIO functions with objectivity and impartiality and in a fair and neutral manner (42 CFR 475.1010(d)) • Demonstrate that it is not a healthcare facility, affiliate, or payer organization. QIOs may not perform reviews of healthcare services other than the review of the quality of care (42 CFR 475.105). Pursuant to Section 1153(c) of the Social Security Act, the contract between CMS and a QIO must provide the right for CMS to evaluate the quality and effectiveness of the QIO in carrying out QIO functions. Further, CMS has the right to negotiate contractual performance objectives and to provide specifications or modifications based on regional or national norms for QIO contractors performing the quality improvement and case review functions. CMS has the responsibility to determine the efficient and effective administration of the QIO Program, establish the program structure, determine the number of contracts and limitations, define the service areas, solicit for QIO services, and negotiate awards. CMS abides by the Federal Acquisition Regulation excepts when Section 1153(e) of the Social Security Act permits an exception.