Authority and Scope for Memoranda of Agreement (MOA)

3000 Authority and Scope for Memoranda of Agreement (MOA) (Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) QIOs enter into Memoranda of Agreement (MOA) with healthcare providers, payers, and other organizations working in the same service area to facilitate the process of performing the case review functions authorized in Section 1154(a) of the Social Security Act and that are outlined in 42 CFR 476 and other chapters of this Manual. Memoranda of Agreement (MOA) are written documents that outline a QIO’s administrative and review responsibilities and the responsibilities of providers, Medicare Administrative Contractors (MACs), and State licensing and certification agencies in connection with certain review requirements under a QIO contract. The intent of a MOA is to be informational in order to facilitate the case review process and to avoid misunderstanding between QIOs and the entities it works with to fulfill its review responsibilities. Each MOA should outline expectations regarding case review activities described in the QIO contract and the applicable responsibilities of a QIO and each entity it works with in the service area. It is the responsibility of a QIO to develop, execute, and maintain MOAs with certain providers of services (i.e., hospitals, critical access hospitals (CAHs), skilled nursing facilities (SNFs), and home health agencies (HHAs), comprehensive outpatient rehabilitation facilities (CORFs), hospices, ) to implement review functions specified in its contract. QIOs are not required to develop MOAs with individual practitioners, nor with physician offices related to Medicare health plan (MHP) reviews. Providers of services (as defined in Section 1861(u) of the Act) must have agreements with QIOs to participate or continue to participate in the Medicare program as required in Section 1866(a) of the Social Security Act. It is the provider’s responsibility to sign and return the agreement. The following regulatory provisions identify the responsibilities of QIOs for review of healthcare services and the obligations of providers of services or payers of services that may apply to each party under MOA: • 42 CFR 476.78 • 42 CFR 476.80 • 42 CFR 476.104 • 42 CFR 482.30(a)(1)) • 42 CFR 489.20(e) MEMORANDA OF AGREEMENT (MOA) WITH PROVIDERS OF HEALTHCARE SERVICES