Evaluation Report Requirements

9220 – Evaluation Report Requirements (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) The QIO written report should contain: 1. The physician review findings as to the medical appropriateness, necessity, and quality of the services provided; 2. The basis for the determination; and 3. When applicable, any advice on additional development needed to properly adjudicate any remaining issues. The report must be signed by the QIO authorized representative (e.g., the Executive Director or Medical Director) and include the titles and qualifications of the physician reviewer(s). When the QIO forwards the report, the QIO should include with it all materials that CMS or the outside agency provided to the QIO. After reviewing the cases included in the QIO report, the QIO can initiate a sanction investigation and recommendation if the issues found are within the QIO area of responsibility. Otherwise, the QIO involvement with the particular case usually ends with the evaluation report submitted to CMS.