Quality Improvement Organization (QIO) Denials

Current Status
12/28/2018: CMS re-issued MM10600 (PDF, 206 KB) on December 21, 2018, regarding MAC follow up actions when they receive the BFCC-QIO Short Stay Review Denial Determinations. CMS provides clarification that:
  • Your MAC will adjust the BFCC-QIO SSR denial decisions as an overpayment (a full claim denial)
  • Clarifies how your MAC is notified of the BFCC SSR denial decisions
  • Clarifies that appeals rights for BFCC-QIO SSR denial determinations are provided through your MAC issuing a demand letter.

Further information is also available in the Palmetto GBA article entitled, "Beneficiary and Family Centered Care Quality Improvement Organizations (QIO) Two-Midnight (2M<) Short Stay Review (SSR) Determinations".

Situation Identified
Beneficiary and Family Centered Care Quality Improvement Organizations (QIO) Two-Midnight (2MN) Short Stay Review (SSR) Determinations are being assessed. 

Impact to Provider
Palmetto GBA will hold QIO Short Stay Review Redeterminations until the Centers for Medicare and Medicaid Services (CMS) provides further instructions. All QIO Short Stay Redeterminations will be processed upon receiving the CMS directive.

Current Status
12/28/2018:
CMS re-issued MM10600 on December 21, 2018, regarding MAC follow up actions when they receive the BFCC-QIO Short Stay Review Denial Determinations. CMS provides clarification that:

  • Your MAC will adjust the BFCC-QIO SSR denial decisions as an overpayment (a full claim denial)
  • Clarifies how your MAC is notified of the BFCC SSR denial decisions
  • Clarifies that appeals rights for BFCC-QIO SSR denial determinations are provided through your MAC issuing a demand letter.

Further information is also available in the Palmetto GBA article entitled, "Beneficiary and Family Centered Care Quality Improvement Organizations (QIO) Two-Midnight (2M<) Short Stay Review (SSR) Determinations".

12/21/2018:  For BFCC-QIO Redetermination requests for determination letters dated prior to September 11, 2018, Palmetto will be assessing these, following CMS instructions and expect to be able to complete these by the end of January 2019. As we complete these assessments and actions, we will provider updates to this CPIL.

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