Beneficiary and Family Centered Care Quality Improvement Organizations (QIO) Two-Midnight (2M<) Short Stay Review (SSR) Determinations
The Beneficiary and Family Centered Quality Improvement Organizations (BFCC-QIOs) conduct patient status reviews on a post-pay basis for Short Stay Reviews (SSR), per 42 Code of Federal Regulations section 405.980.
When the BFCC-QIO identifies improper payments, they notify the provider via a determination letter (also referred to as a results letter). They also notify Palmetto GBA to adjust the claims to initiate the overpayment process. Once Palmetto GBA is notified by the QIO, the claim is adjusted, initiating a remittance advice and an overpayment demand letter generation. The BFCC-QIO determination letter is not a demand letter.
For BFCC-QIO SSR determination letters dated September 11, 2018, or after: if you disagree with the decision, you may request a redetermination (first level appeal) within 120 days from the date of the Palmetto GBA demand letter or remittance advice. BFCC-QIO redetermination requests should be sent to Palmetto GBA Medicare Administrative Contractor (MAC) for Jurisdiction M/J. A request for redetermination should not be made based on receipt of the BFCC-QIO determination letter, prior to the claim adjustment.
Please note that only redeterminations for BFCC-QIO Short Stay Reviews are appealable through the MAC. Quality of Care Reviews and Diagnosis Resource Group (DRG) coding revisions are still required to be sent to the QIO.
MLN Matters Article MM10600
Guidance for Medicare Administrative Contractors (MACs) Processing Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIO) Two-Midnight (2MN) Short Stay Review (SSR) Determinations (PDF, 206 KB)