General Quality of Care Review: Issuing a Claim Denial

5110.3 – General Quality of Care Review: Issuing a Claim Denial (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) A QIO is authorized to deny a practitioner and/or provider’s claim in situations where the QIO has requested information from a practitioner and/or provider and, despite sufficient notice and a reasonable amount of time to respond, the practitioner and/or provider fails to forward the requested information. (See 42 CFR §§476.103(2)(b) and 476.90(b)). 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 should complete the review.