General Quality of Care Review: Referrals

5085 – General Quality of Care Review: Referrals (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Medicare Administrative Contractors (MACs), Medicare health plans (MHPs), State Medicaid survey and certification agencies (SSA), other CMS contractors, and CMS staff may also refer cases involving potential Quality of Care Concerns to QIOs. Before conducting a General Quality of Care Review for these types of referrals, the QIO should contact the CMS COR before proceeding with the review. Only the Request for QIO Review Form (See Appendix 5-8) is authorized for use when an agency or entity refers a potential Quality of Care Concern to a QIO. The QIO should send a copy of the request to the designated COR upon receipt. The QIO may proceed with conducting a General Quality of Care Review in accordance with §§5100-5110. NOTE: At the COR’s discretion, additional information may be requested from the referring agency/entity when the request involves an extensive number of General Quality of Care Reviews. The QIO should conduct General Quality of Care Reviews on all referrals when sufficient information is conveyed to complete the review. When a potential quality of care concern, that is a potential gross and flagrant violation or a substantial violation in a substantial number of cases (more than three) is referred, the QIO must conduct a General Quality of Care Review. (See §§5100-5115.3)