100-10 Quality Improvement Organization Manual: Chapter 12 - Communications, Outreach and Program-related Information Activities

Quality Improvement Organization Manual
Chapter 12 - Communications, Outreach, and Program-
related Information Activities
Table Of Contents
(Rev. 27, 07-08-16)
Transmittals for Chapter 12
12100 - Authorities
12200 - Beneficiary Support and Outreach Activities
12210 - Annual Medical Services Report
12220 - Beneficiary Helpline
12300 - Outreach and Information Collection

12100 - Authorities
(Rev. 27, Issued: 07-08-16, Effective: 07-08-16, Implementation: 07-08-16)
This chapter describes the minimum requirements and responsibilities of QIOs for
communications and outreach. QIO Program communication, outreach, and information
collection activities must comply with the following statutory and regulatory responsibilities as
applicable based upon the QIO functions, care settings, types of reviews, and service areas
defined by CMS in each QIO contract:
• 	Maintain a beneficiary outreach program to apprise providers of healthcare services and
individuals receiving care of their rights to QIO case reviews, and of a QIO’s obligation
for making review determinations as authorized by Section 1154(a)(1) and 1154(a)(4) of
the Social Security Act (the Act)
• 	Provide a physician representing a QIO to meet several times a year with medical and
administrative staff of hospitals whose services are reviewed by the QIO as required by
Section 1154(a)(6)(B)(i) of the Act
• 	Publish and distribute not less often than annually a report that describes the QIO’s
review findings as required by Section 1154(a)(6)(B)(ii) of the Act
• 	Coordinate activities for economical and efficient operation of the program as required
by Section 1154(a)(10) of the Act
• 	Conduct activities deemed necessary for improving the quality of care as required by
Section 1154(a)(18) of the Act
• 	Perform communication and outreach activities in accordance with the confidentiality
and nondisclosure requirements defined in 42 CFR 480 and sections of the Health
Insurance Portability and Accountability Act (HIPAA)
CMS provides QIO contractors with program guides and handbooks that it routinely updates
and revises as the program environment and operations change. The QIO Program
Communications Handbook and the QIO Program Brand Guidelines Manual provide QIO
Program contractors information regarding communications, outreach, information collection,
and development of publications. QIO Program guides also direct QIO contractors to agency
and departmental resources such as the CMS Contractor Website Guidelines and federal
accessibility standards to comply with Section 504 and Section 508 of the Rehabilitation Act of
1973. CMS expects QIOs to use these guidance documents as a reference for operational
questions not addressed in the QIO Manual. The QIO Program Communications Handbook and
the QIO Program Brand Guidelines Manual are available to QIO contractors through the CMS-
furnished secure Intranet site (secure log in is required).

12200 - Beneficiary Support and Outreach Activities
(Rev. 27, Issued: 07-08-16, Effective: 07-08-16, Implementation: 07-08-16)
QIOs conduct a variety of communications and outreach activities that may include positioning
the organization as a resource to the public in support of case review functions and quality of
care improvement initiatives, in addition to outreach efforts that support specific contract
requirements. CMS contracts require QIOs to maintain a communication plan outlining the
specific beneficiary communication and outreach activities it will conduct to educate
beneficiaries, providers, and other non-QIO organizations working in the same service area(s)
about the QIO Program, the exercise of beneficiary rights, and coordination of quality program
activities.
For QIOs that perform case review, the communication plan shall also address planned
outreach activities to comply with the statutory responsibility for physician/provider meetings
required by Section 1154(a)(6)(B)(i) of the Act and Annual Reports required by Section
1154(a)(6)(B)(ii) of the Act.
12210 - Annual Medical Services Report
(Rev. 27, Issued: 07-08-16, Effective: 07-08-16, Implementation: 07-08-16)
For QIOs that perform case review, the communication plan should provide the means to
transparently disseminate the QIO’s review findings and comply with the statutory responsibility
to publish and distribute not less often than annually, a report that describes a QIO’s medical
services review findings as required by Section 1154(a)(6)(B)(ii) of the Act.
The QIO Annual Report, subject to prior-approval of the CMS Contracting Officer’s
Representative, disseminates findings where the QIO has determined that:
• 	inappropriate or unnecessary care was provided
• 	services were furnished in inappropriate settings; or
• 	services did not meet professionally recognized standards of care in its service area(s).
The Annual Report must include statistical data that does not implicitly or explicitly identify any
individual patients, practitioners, or reviewers, and must not contain confidential information as
defined in 42 CFR 480.101. The Annual Report must not report any case-specific or summary
statistical information on cases that a QIO referred to the Office of the Inspector General (OIG)
or to any other federal or state agency responsible for identifying and investigating fraud and
abuse.
12220 - Beneficiary Helpline
(Rev. 27, Issued: 07-08-16, Effective: 07-08-16, Implementation: 07-08-16)

QIOs that perform case review are required to maintain a toll-free helpline, operated according
to QIO contract requirements, to handle beneficiary complaints, provide beneficiary support,
and coordinate with providers and practitioners. QIOs must publish and promote both their own
helpline as well as the national 1-800-MEDICARE helpline for all information related to
beneficiary rights and responsibilities, protections, and various programs and activities.
QIOs should provide information regarding Medicare beneficiary rights and responsibilities,
beneficiary protections (including Hospital-Issued Notices of Noncoverage [HINNs], Medicare
discharge notices, discharge planning, and beneficiary complaints), and appropriate health
education issues related to active projects. QIOs should make appropriate referrals when
information or assistance inquiries are outside of the assigned scope of QIO activities or
responsibilities.
12300 - Outreach and Information Collection
(Rev. 27, Issued: 07-08-16, Effective: 07-08-16, Implementation: 07-08-16)
QIOs promote practices that meet professionally recognized standards and promote
improvements in the quality of health care provided to Medicare beneficiaries. One tactic that
QIOs use to accomplish this goal is the implementation of cooperative quality improvement
projects. As part of such projects, CMS encourages QIOs to develop innovative approaches that
include collaborative efforts with the medical community, use of evidence-based interventions to
change behavior and improve care, communication with beneficiaries and providers, and
monitoring of the health care services furnished to beneficiaries.
The QIO Program Communications Handbook is a resource for guidelines and procedures on
outreach and information collection requirements, including compliance with statutory and
regulatory responsibilities, to support QIOs in developing and evaluating quality of care and
quality improvement interventions. The QIO Program Communications Handbook is available
to QIO contractors through the CMS-furnished secure Intranet site (secure log in is required).

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date 	CR#
R27QIO 	07/08/2016 	QIO Manual Chapter 12 – “Communications,
Outreach, and Program-related Information
Activities”
07/08/2016 	N/A
R7QIO 	08/15/2003 	Initial Issuance of Chapters 	N/A 	N/A
Back to top of chapter