Procedures for the 5-day QIO Review of Alleged Violations of 42

5465 - Procedures for the 5-day QIO Review of Alleged Violations of 42 CFR 489.24 (Rev. 243; Issued: 06-12-26; Effective: 06-12-26; Implementation: 06-12-26) Prior to terminating a hospital from the Medicare program because of possible violation(s) of EMTALA, the CMS location requests the QIO to assess whether the individual involved was provided an appropriate medical screening examination, stabilizing treatment, or an appropriate transfer as required by EMTALA. The QIO 5-day review is mandatory if the CMS location determines that a case involves a possible violation of 42 CFR 489.24 to support possible termination action against a hospital if in fact it violated EMTALA. The CMS location is responsible for providing the QIO with all information relevant to the case that is within its possession and control. The CMS location sends the “Physician Review Outline for Emergency Care Obligations of Medicare Hospitals,” (Exhibit 138) to capture this information. The QIO completes the review within 5 working days upon the receipt of CMS location’s request. The QIO sends the case file back to the CMS location including a copy of the review report. It is not required that the physician reviewer give the hospital and/or the physician an opportunity to respond to the allegations at this time. If the affected physician and/or hospitals have questions concerning the case, they are to consult with the CMS location. The QIO Review is not required in cases where a delay in effecting a sanction would jeopardize the health and safety of individuals or in situations where medical review is inappropriate (e.g., cases where the individual was denied a medical screening examination). The QIO 5-day review is required to seek medical expertise on whether the individual was adequately screened, examined and treated. The CMS location shall release upon request the 5 day QIO review to the affected physician and/or hospital, after the CMS location has made a determination as to whether the hospital violated or is in compliance with EMTALA. In addition, the CMS location may release the QIO review to the complainant or his/her representative upon request. The physician reviewer’s identity is confidential, therefore, when releasing the QIO report the physician’s identity is not to be disclosed unless he or she consents to the release of their identity in accordance with the disclosure regulations at 42 CFR 480.132 and 480.133. The cases in which the CMS location determined that the hospital was in compliance with 42 CFR 489.24 but in violation of 42 CFR 489.20 of the EMTALA regulation do not need to be forwarded to the QIO for review. The CMS location takes action as warranted.