Beneficiary Complaint: Issuing a Claim Denial

5045.3 – Beneficiary Complaint: Issuing a Claim Denial (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) A QIO will deny a provider’s claim in situations where the QIO has requested information from a provider and, despite sufficient notice and a reasonable amount of time to respond, the provider fails to forward the requested information. See 42 CFR §476.90. NOTE: Before processing a claim denial, the QIO should coordinate with the appropriate CMS COR. If the requested medical information is received before the claim denial is finalized, the QIO must stop the denial and complete the review. If the medical information is received after the claim denial has been finalized, payment must be re-instituted. The QIO must then comply with §476.130 and complete the review.