Beneficiary and Family Centered Care Quality Improvement Organizations (QIO) Two-Midnight (2M<) Short Stay Review (SSR) Determinations

Published 12/28/2018

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.

References:

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)