Quality Improvement Organization (QIO) Denials
QIOs are private, mostly not-for-profit organizations, which focus on health care quality assessment services. They are trained to review medical care and help beneficiaries with complaints about the quality of care and to implement improvements in the quality of care available throughout the spectrum of care.
Providers dissatisfied with the initial denial determination from the Quality Improvement Organization (QIO) involving medical necessity, reasonableness of services and appropriateness of setting are entitled to reconsideration. A beneficiary, provider or practitioner (including a practitioner who does not accept assignment) may request reconsideration regardless of whether there is a dollar amount in controversy. Any appeals or reconsideration requests relative to a QIO denial must be sent to the QIO that initiated the denial.
Note: QIO's no longer review excluded services for Medicare Administrative Contractors (MACs).
Please reference the "Quality Improvement Organization Manual" (PDF, 621 KB) section(s): 7015–7050, 7400–7430 and 7560–7580 on the CMS website.
If you receive the following notices on your remittance advice and you disagree with the denial, you must appeal to the QIO that initiated the denial. These requests should not come to Palmetto GBA.
Fiscal Intermediary Shared System (FISS) reason code examples and narratives:
30801: The services were not covered because the services are either excluded from coverage under the Medicare program or that not all the criteria needed to justify the excluded service was met or documented.
30806: PRO Denial — Medical record not provided for review.
For information on Short Hospital Stay Reviews conducted by the QIO, please refer to the article titled "Beneficiary and Family Centered Care Quality Improvement Organizations (QIO) Two-Midnight (2M<) Short Stay Review (SSR) Determinations" for JJ Part A and JM Part A.