C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 431—STATE ORGANIZATION AND GENERAL ADMINISTRATION › Subpart M—Relations With Other Agencies

42 C.F.R. § 431.630

Coordination of Medicaid with QIOs

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(a) The State plan may provide for the review of Medicaid services through a contract with a QIO designated under part 462 of this chapter. Medicaid requirements for medical and utilization review are deemed to be met for those services or providers subject to review under the contract.

(b) The State plan must provide that the contract with the QIO—

(1) Meets the requirements of § 434.6(a) of this part;

(2) Includes a monitoring and evaluation plan by which the State ensures satisfactory performance by the QIO;

(3) Identifies the services and providers subject to QIO review;

(4) Ensures that the review activities performed by the QIO are not inconsistent with QIO review activities of Medicare services and includes a description of whether and to what extent QIO determinations will be considered conclusive for Medicaid payment purposes.

[50 FR 15327, Apr. 17, 1985]
Notes of Decisions
Cited in 4 cases, 1991–2009 · leading case: Kootenai Med. Ctr. v. Idaho Dep't of Health & Welfare, 216 P.3d 630 (Idaho 2009).
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Kootenai Med. Ctr. v. Idaho Dep't of Health & Welfare, 216 P.3d 630 (Idaho 2009). “Pursuant to 42 C.F.R. 431.630, a State plan may provide for the review of Medicaid services through a contract with a QIO.”
Johnson v. Sullivan, 758 F. Supp. 1496 (N.D. Ga. 1991). “650 (c)(2) (exempting from penalty states who contract, under regulatory terms, with other entities to perform reviews) and 42 C.F.R. § 431.630 . § 431.630(b)(1) references the contracting requirements of 42 C.”
Kootenai Med. Ctr. v. Idaho Dept. of Health & Welfare (Idaho 2009). “Pursuant to 42 C.F.R. 431.630, a State plan may provide for the review of Medicaid services through a contract with a QIO.”
Kootenai Med. Ctr. v. Idaho Dept. of Health & Welfare (Idaho 2009). “Pursuant to 42 C.F.R. 431.630, a State plan may provide for the review of Medicaid services through a contract with a QIO.”
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