CMS Manual System  Department of Health & 
Human Services (DHHS) 
Pub 100-10 Medicare Quality Improvement  Centers for Medicare & 
Medicaid Services (CMS) 
Organization 
Transmittal 29  Date: October 21, 2016 
 
SUBJECT: QIO Manual Chapter 3 Memoranda of Agreement for Case Review 
 
I. SUMMARY OF CHANGES:  The Quality Improvement Organization (QIO) Program originated with 
the Peer Review Improvement Act of 1982 (P.L. 97-248,  141-143, 96 Stat. 324) and is authorized by 
Title XI Part B and Title XVIII the Social Security Act (the Act). The QIO provisions in the Act were most 
recently amended in 2011 by the Trade Adjustment Assistance Extension Act (P.L. 112-40,  261, 125 Stat. 
401).  
 
Memoranda of Agreement (MOA) requirements and guidance, as updated in this chapter, only pertain to 
QIOs under contract with CMS to perform case review functions (See 42 CFR 476). The revision also 
updates terminology and associated acronyms to be consistent with current regulations. 
 
EFFECTIVE DATE: * October 21, 2016 
*Unless otherwise specified, the effective date is the date of service. 
IMPLEMENTATION DATE: * October 21, 2016 
 
 
Disclaimer for manual changes only: The revision date and transmittal number apply only to red 
italicized material. Any other material was previously published and remains unchanged. However, if this 
revision contains a table of contents, you will receive the new/revised information only, and not the entire 
table of contents. 
 
II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated) 
R=REVISED, N=NEW, D=DELETED 
 
R/N/D  CHAPTER / SECTION / SUBSECTION / TITLE 
 Table of Contents 
R 
3/3000/Authority and Scope for Memoranda of Agreement (MOA) 
R 
MEMORANDA OF AGREEMENT (MOA) WITH PROVIDERS OF SERVICES 
R 
3/3005/Agreements with Providers of Services 
R 
3/3010/Hospital Memorandum of Agreement (MOA)  
R 
R  3/3015/Home Health Agencies (HHAs) and Skilled Nursing Facilities (SNFs) 
Memoranda of Agreement (MOA) 
3/3020/Memorandums of Agreement (MOAs) With Specific Providers 
D 
  R/N/D  CHAPTER / SECTION / SUBSECTION / TITLE 
R  AGREEMENTS WITH PAYERS OF HEALTHCARE SERVICES 
R  3/3100/Medicare Administrative Contractor (MAC) Joint Operating Agreements 
(JOA) 
D  3/3105/Scope 
D   3/3110/Intermediary/Carrier Memorandum of Agreement (MOA) Specifications 
R  3/3200/Memorandum Of Agreement (MOA) with State Agencies Responsible for 
Licensing and Certification of Providers and Practitioners 
3/3210/Memorandum of Agreement (MOA) With State Agencies Responsible for 
D 
Licensing\Certification of Providers\Practitioners 
R  EXHIBITS 
3/Exhibit 3-1/ Model Memorandum of Agreement (MOA) Cover Letter for 
R 
Providers of Services   
 
3/Exhibit 3-2 /Model Memorandum of Agreement (MOA) for Providers 
R 
3/Exhibit 3-3/Model Memorandum of Agreement (MOA) for State 
R 
Licensing/Certification Agency 
3/Exhibit 3-4/Model Joint Operating Agreement (JOA) for QIOs and Medicare 
N 
Administrative Contractors 
 
III. FUNDING: 
For Medicare Administrative Contractors (MACs): 
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined 
in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is 
not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically 
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to 
be outside the current scope of work, the contractor shall withhold performance on the part(s) in question 
and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions 
regarding continued performance requirements. 
 
IV. ATTACHMENTS: 
 
Manual Instruction 
 
 
 
 
 
 
 
 
 
  Quality Improvement Organization Manual 
Chapter 3 Memoranda of Agreement for Case Review 
 
(Rev. 29, Issued: 10- 21-16) 
 
Table of Contents 
 
 
Transmittals for Chapter 3 
 
 
3000   Authority and Scope for Memoranda of Agreement (MOA) 
 
MEMORANDA OF AGREEMENT (MOA) WITH PROVIDERS OF SERVICES  
 
3005  Agreements with Providers of Services  
3010  Hospital Memorandum of Agreement (MOA)  
3015   Home Health Agencies (HHAs) and Skilled Nursing Facilities (SNFs) Memoranda of Agreement 
(MOA) 
 
AGREEMENTS WITH PAYERS OF HEALTHCARE SERVICES  
 
3100   Medicare Administrative Contractor (MAC) Joint Operating Agreements (JOA) 
 
 
3200   Memoranda of Agreement (MOA) with State Agencies Responsible for Licensing and Certification 
of Providers and Practitioners 
 
EXHIBITS 
 
Exhibit 3-1  Model Memorandum of Agreement (MOA) Cover Letter for Providers of Services 
Exhibit 3-4  Model Joint Operating Agreement (JOA) for QIOs and Medicare Administrative Contractors 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3000  Authority and Scope for Memoranda of Agreement (MOA) 
(Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) 
  QIOs enter into Memoranda of Agreement (MOA) with healthcare providers, payers, and other 
organizations working in the same service area to facilitate the process of performing the case review 
functions authorized in Section 1154(a) of the Social Security Act and that are outlined in 42 CFR 476 and 
other chapters of this Manual.  
 
Memoranda of Agreement (MOA) are written documents that outline a QIOs administrative and review 
responsibilities and the responsibilities of providers, Medicare Administrative Contractors (MACs), and State 
licensing and certification agencies in connection with certain review requirements under a QIO contract. The 
intent of a MOA is to be informational in order to facilitate the case review process and to avoid 
misunderstanding between QIOs and the entities it works with to fulfill its review responsibilities. Each MOA 
should outline expectations regarding case review activities described in the QIO contract and the 
applicable responsibilities of a QIO and each entity it works with in the service area. 
 
It is the responsibility of a QIO to develop, execute, and maintain MOAs with certain providers of services (i.e., 
hospitals, critical access hospitals (CAHs), skilled nursing facilities (SNFs), and home health agencies (HHAs), 
comprehensive outpatient rehabilitation facilities (CORFs), hospices, ) to implement review functions specified 
in its contract. QIOs are not required to develop MOAs with individual practitioners, nor with physician offices 
related to Medicare health plan (MHP) reviews. Providers of services (as defined in Section 1861(u) of the Act) 
must have agreements with QIOs to participate or continue to participate in the Medicare program as required in 
Section 1866(a) of the Social Security Act. It is the providers responsibility to sign and return the agreement.  
 
The following regulatory provisions identify the responsibilities of QIOs for review of healthcare services 
and the obligations of providers of services or payers of services that may apply to each party under MOA: 
  42 CFR 476.78 
  42 CFR 476.80 
  42 CFR 476.104 
  42 CFR 482.30(a)(1)) 
  42 CFR 489.20(e) 
 
MEMORANDA OF AGREEMENT (MOA) WITH PROVIDERS OF HEALTHCARE 
SERVICES  
 
3005  Agreements with Providers of Services 
(Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) 
 
MOAs with providers of services (i.e., hospitals, CAHs, SNFs, HHAs, CORFs, and hospices) should address 
the statutory activities (Sections 1154(a)(1), 1154(a)(4)(A), 1154(a)(14), 1866(a)(F)(i), 1866(a)(F)(ii), and 
1866(a)(3)(A) of the Act), as well as those activities required by CMS in the QIO contract. Providers must 
furnish patient care data including patient medical records requested by a QIO to perform the reviews 
specified in the QIO contract (See 42 CFR 476.78 (a) and (b)). Results of QIO case reviews may include 
denial of payment for admission, DRG changes, and the identification of confirmed quality of care concerns. 
   
At a minimum, the MOA must include the QIOs responsibilities and the responsibilities of the provider 
regarding the following, if applicable: 
 
  Case Review -- Identify requirements for provider compliance in furnishing data and information 
necessary for QIO case reviews to determine whether the services were reasonable and medically 
necessary and furnished in the appropriate setting, and whether they met professionally recognized 
standards of care.  
  Data Analysis -- Review of individual patient care data furnished by providers to ensure the validity of 
all diagnostic and procedural information. 
  Claims Analysis -- Review of payment data to determine whether payment must be made for the 
services furnished (as appropriate). 
  Complaint Analysis -- Review of cases in response to written beneficiary complaints about the quality 
of services.    Confidentiality and Disclosure -- Include confidentiality and disclosure requirements in all agreements 
in accordance with 42 CFR Part 480. 
  Beneficiary Rights Outreach and Education Activities -- Conduct programs to inform Medicare 
enrollees about QIO review programs, the role of a QIO, grievance and complaint procedures, 
confidentiality and disclosure rights and notice requirements. 
  Timing of Review -- Conduct review within the timeframes specified in the QIO contract between CMS 
and the QIO. 
  Location of Review -- Specify all locations where QIO review of cases may take place (e.g., at the QIO 
or on-site review at the providers facility). 
  Quality Improvement Initiative (QII) Referrals-- Specify the process for the referral of confirmed quality 
of care concerns identified by a QIO that conducts case review to another QIO entity in the service area 
that is responsible for conducting quality improvement initiatives. 
  Miscellaneous -- Identify additional review activities and procedures as prescribed by CMS in the QIO 
contract. 
 
QIOs may also want to include language to address the exchange of information with the MAC, Clinical 
Data Abstraction Center (CDAC), CMS, Office of the Inspector General (OIG), and State agency referrals in 
the MOA. 
 
Signature Requirements 
 
Both parties must sign the MOA. If a provider refuses to sign the MOA, the QIO must inform the CMS 
Contracting Officer Representative (COR) of this matter. 
 
MOA Modifications  
 
QIOs and providers of services may modify MOAs when changes in contract requirements necessitate 
changes between the QIO and the provider. Representatives of the QIO and the provider organization must 
sign the revised MOA. 
 
Failure to Return, Sign, or Honor the Terms of a MOA  
 
If a provider fails to return the MOA by the requested due date, refuses to sign the MOA, or fails to honor 
the provisions of the MOA, the QIO should document the efforts taken to resolve the issues and obtain a 
signed MOA and refer the circumstances to the COR for resolution. 
 
3010  Hospital Memorandum of Agreement 
(Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) 
 
In accordance with 42 CFR 489.20(e), hospitals that provide inpatient hospital services paid under the 
Prospective Payment System (PPS) are required to maintain an agreement with a QIO to review the: 
  Validity of diagnostic information provided  
  Completeness, adequacy, and quality of care provided 
  Appropriateness of admissions and discharges 
  Appropriateness of care provided with respect to services for which payment may be made under Part A 
of Medicare 
 
The hospital MOA should include appropriate specifications listed in Section 3005 of this chapter. QIOs 
may follow the cover letter and model agreement (See Exhibits 3-1 and 3-2) when preparing the MOA. 
 
3015  Home Health Agencies (HHAs) and Skilled Nursing Facilities (SNFs) Memoranda 
of Agreement 
(Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) 
  Under Section 1866(a)(1)(F) of the Act, QIOs must also enter into agreements with HHA and SNFs. The 
HHA and SNF MOAs should include appropriate specifications provided in Section 3005 of this chapter. 
QIOs may follow the cover letter and model agreement (See Exhibits 3-1 and 3-2) when preparing the MOA. 
 
QIOs may develop one MOA with a parent HHA operating in a state that has branches located in the same 
state as the parent agency. List the name and address of all branch office locations in the MOA with the 
parent agency. Separate MOAs are required for subunits of a parent HHA that serves patients in geographic 
areas different from that of the parent HHA because these subunits have their own agreement number. HHA 
subunits are semi-autonomous organizations and must independently meet the conditions of participation for 
HHAs (See 42 CFR 484.2). 
 
AGREEMENTS WITH MEDICARE ADMINISRATIVE CONTRACTORS (MACS)  
 
3100  Medicare Administrative Contractor (MAC) Joint Operating Agreements 
(Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) 
 
Medicare Administrative Contractors (MACs) are private entities under contract with CMS to process 
claims for Part A and Part B Medicare services in specific jurisdictions. MACs responsible for processing 
Medicare Part A and B claims must cooperate with the QIO for data exchange requirements necessary for 
the QIO to fulfill its case review requirements specified in the contract. Regulations at 42 CFR 476.80 
require that each MAC have an agreement with the QIO and that terms of the Joint Operating Agreement 
(JOA) reflect mutually agreeable conditions necessary for data exchange requirements in recognition of the 
unique capabilities and requirements of each party. QIOs performing case reviews must maintain 
agreements with each MAC processing claims in the QIO services area(s) designated in the QIO contract. 
 
The QIO and the MAC should identify the specific claims and review determination information that each 
party will share with the other, and the methods the QIO will use to communicate its review determination. 
The JOA should specify the roles and responsibilities of each party regarding QIO payment determinations 
and the methods each party will use to communicate that information. 
 
Elements of JOAs    
 
At a minimum, the JOAs with MACs should include the following elements below: 
 
  Scope of QIO reviews  Include the types of review services and the services areas that the QIO is 
responsible for in accordance with its contract with CMS. 
  Claims Review -- Specify how the QIO will receive records for quality of care reviews not provided 
directly by CMS. The JOA must distinguish between hard copy and electronic submissions and reference 
the format for any electronic submission. 
  Data Review and Exchange -- Specify how the QIO will receive records subject to QIO review that are 
not provided directly by CMS. Provide for full compliance with CMS requirements for the exchange of 
CMS-approved adjustment records and reconciliation of pending adjustment totals. Specify any 
physician or facility identifiers used by the MAC other than the CMS certification number and the 
National Provider Identifier (NPI). 
  Coordination -- Communicate confidentiality concerns or issues related to QIO activities. 
  Notification of Denial and Reconsideration Determinations -- Provide for transmission of QIO denial 
letters/determinations to servicing MACs and, when necessary for medical review, copies of the 
patients medical records used. Include a negotiated processing timeframe for QIO notification to the 
MACs of denials, reconsideration reversals, or modifications, and changes as a result of DRG 
validations and reviews. 
  Information Exchange -- Include details for implementing the following activities: 
  Use of standard forms for referrals from MACs to QIOs 
o
  Exchange of medical review policies 
o
  Attendance at meetings (which may be conference calls) 
o   QIO review and comment on new MAC policies for new technology  
o
  Internal contacts and procedures for resolving problems and exchanging any needed information or 
o
negotiating changes timely 
 
Signature Requirements  
 
Both parties must sign the JOA. If a MAC refuses to sign the JOA, the QIO must inform the CMS QIO COR 
of this matter. 
 
MOA Modifications  
 
QIOs may modify JOAs when changes in contract requirements necessitate additional changes between the 
QIO and the MAC. Representatives of the QIO and a representative of the MAC must sign the revised JOA. 
 
Failure to Honor the Terms of a MOA  
 
If a MAC fails to return the JOA by the requested due date, refuses to sign the JOA, or fails to honor the 
provisions of the JOA, the QIO should document the efforts taken to resolve the issues and obtain a signed 
JOA, and refer the circumstances to the QIO COR for resolution. 
 
Notify the CMS QIO COR immediately if any of the following occur: 
  The QIO is unable to reach an agreement with any MAC 
  The MAC fails to comply with the terms of an existing JOA 
  The QIO is unable to comply with the terms of an existing JOA 
 
If a MAC fails to comply, CMS reserves the right to determine if the QIO made reasonable efforts to resolve 
the issue. 
 
If a QIO fails to honor the provisions of the JOA, CMS reserves the right to determine if this is a breach of 
the QIOs review responsibilities stipulated in the contract. 
 
AGREEMENTS WITH OTHER ORGANIZATIONS 
 
3200 Memoranda of Agreement with State Agencies Responsible for Licensing and 
Certification of Providers and Practitioners 
(Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) 
 
The QIO should meet with the State Agencies responsible for licensing and certification of Medicare 
providers and practitioners subject to QIO review to discuss the types of information and data exchange that 
would be useful to both the QIO and the licensing and certification agencies. QIOs and State agencies are 
not required by statute or regulation to execute a MOA, but may elect to develop MOAs to outline each 
partys agreement to exchange information and data. The MOA is a written document that outlines QIO 
administrative and review responsibilities and the responsibilities of the State agencies responsible for licensing 
and certification of providers and practitioners, necessary to accomplish certain review requirements under the 
QIO contract. QIOs should work with the state agencies responsible for licensure and certification of 
Medicare providers and practitioners in each service area where a QIO performs case review to 
communicate the QIOs review responsibilities, and identify potential data and information exchange 
opportunities that may arise from either party. 
 
Signature Requirements  
 
Both parties should sign the MOA. If a state agency elects not to enter into an MOA, the QIO should inform 
the CMS COR of this matter. 
 
MOA Modifications    
QIOs may modify MOAs when changes in contract requirements necessitate additional changes between the 
QIO and state agency. Representatives of the QIO and a representative of the state agency should sign the 
revised MOA. 
 
Failure to Return, Sign, or Honor the Terms of a MOA  
 
If a state agency responsible for licensing/certification fails to return the MOA by the requested due date, or 
refuses to sign the MOA, or fails to honor the provisions of a MOA, the QIO should document the effort taken 
and notify the CMS COR. CMS expects both parties to a MOA to honor the agreements. A QIO should notify the 
CMS COR immediately if any of the following occur:  
  The QIO is unable to reach an agreement with any State agency  
  A state agency fails to comply with the terms of an existing MOA  
  The QIO is unable to comply with the terms of an existing MOA 
 
If a QIO fails to honor the provisions of the MOA, CMS reserves the right to determine if this is a breach of the 
QIOs review responsibilities. 
 
Exhibit 3-1 Model Memorandum of Agreement (MOA) Cover Letter for Providers of 
Services  
(Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) 
 
QIO Letterhead  
 
Dear (Name of Provider of Services):  
 
The (QIO Name) is the Quality Improvement Organization (QIO) authorized by the Medicare Program to 
review healthcare services provided to Medicare beneficiaries in the area/state(s) of 
____________________. As you may already know, we review patient medical records to determine 
whether services delivered to these beneficiaries meet professionally recognized standards of care, are 
medically necessary, and delivered in the most appropriate setting. In addition, we conduct reviews 
generated by requests from Medicare beneficiaries that include appeals related to notices of discharge 
and/or notices of service terminations and written complaints about the quality of Medicare services they 
have received. We may refer confirmed quality of care concerns to another QIO entity under contract with 
CMS to work with your organization on healthcare quality improvement initiatives. 
  
In order to participate in the Medicare program, hospitals, critical access hospitals, skilled nursing facilities, 
hospices, comprehensive outpatient rehabilitation facilities (CORF), and home health agencies are required 
to have a Memorandum of Agreement (MOA) with a QIO under Section 1866(a)(1)(F) of the Social 
Security Act.  
 
MOAs facilitate the review process by outlining the QIOs administrative and review responsibilities and the 
providers responsibility in assisting us in accomplishing our review requirements. MOAs are also 
informational. (QIO name) wants to inform (name of State) hospitals, critical access hospitals, skilled 
nursing facilities, hospices, CORFs and home health agencies of (a) (QIO name) procedures with respect to 
certain contract obligations, (b) review and appeal rights, which providers have with respect to these 
obligations These requirements are based on the Statutory citations provided below: 
 
  Section 1866(a)(1)(E) of the Act requires providers of services to release to QIOs any data 
related to patients  
 
  Section1866(a)(1)(F)(i) of the Act requires hospitals which provide inpatient hospital services 
paid under the Prospective Payment System (PPS) to maintain an agreement with a QIO (or 
with a professional standards review organization if there is such an organization in 
existence in the area in which the hospital is located) to review the validity of diagnostic  information provided by such hospital, the completeness, adequacy and quality of care 
provided, the appropriateness of admissions and discharges, and the appropriateness of care 
provided  
 
  Section 1866(a)(1)(F)(ii) of the Act requires hospitals, critical access hospitals, skilled 
nursing facilities, hospices, CORFs, and home health agencies to maintain an agreement with 
a QIO to perform certain functions  
 
  Section 1869(b)(1)(F) of the Act requires the Secretary to provide an expedited determination 
or an expedited reconsideration for Medicare beneficiaries who have been notified of their 
impending termination of services or discharge from a comprehensive outpatient 
rehabilitation facility, home health agency, hospice, or skilled nursing facility; under 42 CFR 
Part 405, Subpart J, the QIO for a region is required to hear and make these determinations 
and reconsiderations. 
 
 
Please review and sign the enclosed MOA, and return it to the office listed below by the due date indicated.  
 
(Address of QIO)  
 
If you have questions, please contact us at:  
(QIO Contact Person)  
(QIO Telephone Number)  
 
Sincerely yours,   
 
Enclosure: (See Exhibit 3-2)  
 
 
Exhibit 3-2 - Model Memorandum of Agreement (MOA) for Providers  
(Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) 
 
Memorandum of Agreement between (Name of QIO) and (Name of Provider)  
 
I.  Agreement  
 
A.  Parties  
 
The parties to this agreement are the (QIO name) hereinafter referred to as ____________________ and 
(Name of Provider) hereinafter referred to as hospital, critical access hospital, skilled nursing facility, home 
health agency, hospices, and comprehensive outpatient rehabilitation facilities. 
 
B.  Statutory Specifications  
 
  Section 1154(a)(1) of the Social Security Act (the Act) requires QIOs to review healthcare services 
furnished to Medicare beneficiaries by physicians, other healthcare professionals, providers, and 
suppliers as specified in the contract with the Secretary.  
 
  Section 1154(a)(4)(A) of the Act requires that a reasonable proportion of the QIOs activities are 
involved in reviewing, under paragraph (a)(1)(B), the quality of services and that a reasonable 
allocation of these activities be made among different settings.  
 
  Section1154(a)(14) of the Act requires that a QIO conducts an appropriate review of all written 
complaints from beneficiaries about the quality of services not meeting professionally recognized 
standards of care.    
  Section1866(a)(1)(F)(i) of the Act requires hospitals which provide inpatient hospital services paid 
under the Prospective Payment System (PPS) to maintain an agreement with a QIO (or with a 
professional standards review organization if there is such an organization in existence in the area 
in which the hospital is located) to review the validity of diagnostic information provided by such 
hospital, the completeness, adequacy and quality of care provided, the appropriateness of admissions 
and discharges, and the appropriateness of care provided for which the hospital is seeking additional 
payments. 
 
  Section 1866(a)(1)(F)(ii) of the Act requires hospitals, critical access hospitals (CAHs), skilled 
nursing facilities (SNFs), and home health agencies (HHAs) to maintain an agreement with the QIO 
to perform certain functions listed in Section1866(a)(3)(A).  
 
  Section 1866(a)(3)(A) of the Act requires QIOs, under the MOA, to perform functions described 
under the third sentence in Section1154(a)(4)(A) related to quality of services and under 
Section1154(a)(14) related to beneficiary complaints. 
 
  Section 1869(b)(1)(F) of the Act requires the Secretary to provide an expedited determination or an 
expedited reconsideration for Medicare beneficiaries who have been notified of their impending 
termination of services or discharge from a comprehensive outpatient rehabilitation facility, home 
health agency, hospice, or skilled nursing facility; under 42 C.F.R. Part 405, Subpart J, the QIO for 
a region is required to hear and make these determinations and reconsiderations. 
 
II.  QIO Program  
 
The Quality Improvement Organization (QIO) Program originated with the Peer Review Improvement Act 
of 1982 and is authorized by Title XI Part B and Title XVIII the Social Security Act (the Act).  
 
The goal of the QIO program is to improve the quality of care for Medicare beneficiaries, including 
addressing individual complaints or requests for QIO review and to protect the Medicare Trust Fund. The 
QIO is to achieve this goal through performance of various case review directives promulgated by CMS in 
the QIO Contract, as discussed below.  
 
II. Purpose of Agreement  
 
The purpose of this Agreement is to define the administrative relationship that will exist between parties in 
the exchange of data and information. This MOA is required by the Medicare statute and regulation, and 
certain QIO contract directives, and is consistent with guidance in the QIO Manual. It is intended to be 
informational. (QIO name) wants to inform (Name of state) hospitals, SNFs, HHAs, hospices, and 
comprehensive outpatient rehabilitation facilities (CORFs) of (a) (QIO name) procedures with respect to 
certain contract obligations, (b) review and appeal rights which providers have with respect to these 
obligations, and (c) opportunities providers have to collaborate with (Name of QIO) in local and national 
quality improvement projects. 
 
III.  Effective Date  
 
This Agreement shall be effective upon execution and shall remain in effect so long as (QIO name) is the 
Quality Improvement Organization under contract with CMS for the area in which the provider is located, or 
is terminated in accordance with Section VIII of this Agreement, or the provider withdraws or is terminated 
from the Medicare program.  
 
IV.  Responsibilities of Parties  
 
MOAs with hospitals, HHAs, SNFs, CORFs, hospices, and CAHs reflect the specific QIO review 
responsibilities referenced in Section 1866(a)(1)(F), Section 1866(a)(3)(A), Section1154(a)(4)(A), and  Section 1154(a)(14) of the Act as well as the responsibilities of each provider regarding QIO contract 
activities.  
 
At a minimum, the MOA stipulates that a reasonable proportion of QIO activities be involved in reviewing, 
under Section 1154(a)(1)(B) of the Act, the quality of services and that a reasonable allocation of these 
activities is made among different settings.  
 
In addition, Section1154(a)(14) of the Act requires that QIOs conduct an appropriate review of written 
complaints from beneficiaries about the quality of services not meeting professionally recognized standards 
of care.  
 
In addition, (Name of QIO) agrees that it will assume responsibility for performing the following activities 
mentioned in the terms of the Medicare QIO contract:  
 
A.  QIO Responsibilities  
 
The list of QIO Responsibilities in the areas below is not all-inclusive. Many QIO activities are specified in 
the QIO contract and may change with each CMS contract period.  
 
(QIO name) shall assume the federally mandated responsibility for performing the following Medicare 
review activities: 
 
1.  Case reviews that involve non-physician screening and physician review of patient medical records 
that are required in the QIO contract. Mandatory case review categories include Emergency Medical 
Treatment and Labor Act (EMTALA), assistant surgeon at cataract surgery, beneficiary complaints, 
hospital notices of non-coverage, important message from Medicare appeals of hospital discharges 
and Medicare appeal rights, (including MHP fast-track appeals, termination of services or discharge 
from a CORF, HHA, hospice, or SNF), hospital-requested higher-weighted DRG adjustments, 
potential concerns identified during project data collections, and referrals made by the OIG, MACs, 
and CMS.  
2.  Communication activities to educate beneficiaries about how to exercise their rights to QIO reviews 
and that provide information for education of healthcare providers, beneficiaries, and others 
responsible for payment about QIO review determinations and rights to reconsideration and appeal.  
3.  Referral to other QIO entities under contract with CMS that are responsible for quality improvement 
initiatives and may be able to assist your organization in identifying the root cause of a concern, 
develop a framework in which to address quality of care concerns and improve a process or system. 
4.  Other Review Activities including but not limited to an annual monitoring of Medicare physician 
attestations statements. 
 
 
B.  Provider Responsibilities  
 
Providers of services that submit Medicare claims to CMS must cooperate in the assumption and 
conduct of QIO review in accordance with 42 CFR 476.78. The provider must: 
 
  Submit patient medical records and other information to the QIO as requested within the timeframes 
identified in the medical record request, which are needed for conducting offsite review activities.  
 
  Allocate adequate space to QIO staff for conducting onsite review and cooperative project activities 
if requested by the QIO, and shall provide patient medical records and other related information at 
the time of the QIOs visit or upon receipt of a written request for patient medical record 
documentation. 
 
  Adhere to applicable Federal laws and regulations that protect the confidentiality of medical review 
information as well as applicable State laws and regulations.    
  Request technical assistance from the QIO or accept technical assistance from the QIO assigned by 
CMS to support quality improvement activities.  
 
A completed and signed MOA signed by a provider should also include the following: 
 
  Identification of a designated liaison person(s) who will represent the Provider for purposes of 
correspondence and communications between the Provider and the QIO under this Agreement  
 
  The person(s) serving as a liaison between the Provider and the QIO will be responsible for the 
maintenance of correspondence, the dissemination of QIO information, the coordination of responses to 
QIO inquires, and any other duties related to QIO activity as deemed necessary by the Provider. The 
QIO shall be notified in writing in the event a change is made in the designation of the QIO liaison staff 
person.  
 
V.  Confidentiality of Records and Other Data 
 
 (QIO name) and (providers name) recognize the inherent right of the individual to privacy and at the same 
time acknowledges the need for adequate information in order to carry out its activities under this 
Agreement. To protect the confidentiality of data acquired by (QIO name) in carrying out its responsibilities 
under this contract, (QIO name) is bound by Section 1160 of the Act and applicable regulations in 42 CFR 
Part 480. (QIO name) shall ensure the confidentiality and security of the (provider type) records and data 
from the time the records/data are acquired by (QIO name) until their destruction in accordance with the 
statute and regulations.  
 
The (provider type) shall adhere to the applicable State and Federal laws that protect the confidentiality of 
medical review information.  
 
VI.  Modification of Agreement  
 
This Agreement may be amended by (QIO name) at any time as necessary to conform with any changes or 
modifications of relevant State or Federal laws or applicable regulations, CMS transmittals, program 
directives, or instructions issued pursuant to applicable laws and regulations. In the event of such an 
amendment, (QIO name) shall provide the (provider type) with notice of any such new or revised laws, 
regulations, CMS transmittals, program directives, or instructions, etc.  
 
VII.  Termination of Agreement  
 
This agreement may be terminated, upon advance written notice by one party to the other, as follows:  
 
A.  By the (provider type) without cause with 60-day prior written notice to (QIO name) if the (provider 
type) determines that it is no longer required to be a party to this agreement as a condition of 
participation in the Medicare program.  
 
B.  In the event that the (QIO name) status as a QIO and/or the (provider type) status, as an institution 
qualified and eligible to receive reimbursement for services and items provided under the Medicare 
program, is terminated by CMS. 
 
C.  In the event that CMS terminates this agreement, (Name of QIO) shall notify (provider type) of 
termination.  
 
D.  In the event that the QIO and the provider cannot agree to a modification to the Agreement.  
 
VIII.  Miscellaneous Provisions    
A.  Severability  
 
Should any clause, portion, or section of this Agreement be unenforceable or invalid, this shall not affect the 
enforceability or validity of the remainder of this Agreement. Should any particular provision(s) of this 
Agreement be held unreasonable or unenforceable for any reason, the provisions shall be given effect and 
enforced to whatever extent would be reasonable and enforceable.  
 
B.  Governing Law  
 
To the extent procedures for resolving any dispute under this Agreement are not available through the 
Department of Health & Human Services, this Agreement and any disputes arising under it shall be 
governed by laws of the State of (Name of State of providers location).  
 
C.  Resolution of Disputes  
 
If problems in the parties' relationship present themselves, or in the event a dispute arises between the 
parties, the parties shall attempt to resolve those differences in good faith. If a good faith dispute resolution 
should fail, (QIO name) shall notify CMS, and CMS shall advise the parties concerning the matter in 
dispute.  
 
D.  Notices  
 
Notice from (QIO name) concerning this Agreement shall be directed to the party specified on the signature 
page below. Other notices from (QIO name) which are issued as a result of activities required by this 
Agreement shall be directed to an individual designated by the (provider type). (Name of Provider) is 
responsible for notifying (QIO name) about any change in the person designated to receive such 
communications.  
 
Notices from the (provider type) in response to (QIO name) notices shall be directed to the individual or 
department specified in (QIO name) communications. 
 
Change of Ownership:  
In the event of a change of ownership, the new owners will assume all obligations in the current MOA.  
 
Agreement to Terms  
 
The undersigned acknowledge that this Agreement is made pursuant to Sections1866(a)(1)(F) of the Act, 42 
CFR Part 476, the QIO Manual, and certain QIO contract directives, and agree to abide by the terms and 
conditions set forth. 
 
Provider name: ______________________________  
 
Address: ___________________________________  
__________________________________________  
 
Signature: __________________________________  
 
Date: ______________________________________  
 
Name, address, and title of individual (QIO) executing Agreement:  
___________________________________________  
___________________________________________  
___________________________________________  
  Signature: __________________________________  
 
Date: ______________________________________  
 
 
 
 
Exhibit 3-3 - Model Memorandum of Agreement (MOA) for State 
Licensing/Certification Agency  
(Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) 
 
Memorandum of Agreement between (QIO Name) and (State Licensing Agency/Certification Body 
Name)  
 
I.  Agreement  
 
A.  Parties to the Agreement  
 
The parties to this Memorandum of Agreement are the (State Licensing Agency/Certification Body Name 
and Address), hereinafter referred to as the (____________________), and the (QIO name).  
 
B.  Statutory/State Law Specifications  
 
Quality Improvement Organizations (QIOs) are authorized to perform Medicare case review as defined in 
titles XI and XVIII of the Social Security Act (hereinafter referred to as the Act). This authorization is made 
effective through the QIO's contract with the Centers for Medicare & Medicaid Services (CMS). Section 
1160(b)(1)(C) of the Act specifically authorizes QIOs to assist State agencies recognized by the Secretary as 
having responsibility for licensing/certification by providing data and information (at the request of such 
agency) insofar as such data and information are required by the agency or body to carry out its respective 
function which is within the jurisdiction of the agency or body under State law. State licensing 
agencies/certification bodies may provide data/information to QIOs in accordance with applicable State law.  
 
C.  Purpose of Agreement  
 
The purpose of this Agreement is to define the administrative relationship that will exist between the parties 
in the exchange of data and information that relates to promoting appropriate and professionally recognized 
standards of care to Medicare beneficiaries.  
 
D.  Acknowledgments  
 
The (QIO name) and (State Licensing Agency/Certification Body name) share a mutual interest in 
exchanging data and information that may be used to improve healthcare outcomes. Participants to this 
Agreement are expected to provide data/information as specified herein.  
 
E.  Term of Agreement  
 
This Agreement is effective on and after _____________, 20____ and until such time as a new Agreement is 
deemed necessary by the parties. 
 
F.  Provisions of Agreement  
 
  Applicable Law -- This agreement shall, to the extent applicable, be governed by and 
construed in accordance with the provisions of titles XI and XVIII of the Act, and applicable 
Federal regulations.  
    Severability -- If any provision of this Agreement is determined to be inconsistent with any 
Federal or State law or regulation, the Federal or State law or regulation shall control. In 
cases where Federal and State law conflict, the Federal law shall prevail. However, the 
remainder of this agreement shall remain valid.  
 
  Medicare Liability -- This Agreement shall not be construed to increase either party's 
financial liability beyond that required by Medicare (i.e., the release or sharing of QIO data 
will be performed within the QIO's current operating budget).  
 
I.  QIO Responsibilities  
The (QIO name) has the responsibility to provide (in accordance with the dates and timeframes set forth in 
this section) to the (State Licensing Agency/Certification Body Name) the data/information listed in this 
section.  
 
(Enter Responsibilities)  
 
II.  Licensing Agency/Certification 
 
The (State Licensing Agency/Certification Body name) has the responsibility to provide (in accordance with 
the dates and timeframes set forth in this section) to the (QIO name) the data/information listed in this 
section.  
 
(Enter Responsibilities)  
 
III.  Confidentiality and Disclosure  
 
The parties agree to comply with confidentiality requirements of Section 1160 of the Act and regulations at 
42 CFR Part 480 as well as confidentiality requirements under all other applicable Federal statutes, Federal 
regulations, and any applicable State law. None of the confidential information or any data derived from the 
information will be released by the recipient to any other organization or individual in confidential form 
without prior CMS approval. Appropriate administrative, technical, procedural, and physical safeguards 
shall be established by the recipient to protect the confidentiality of the data and to prevent unauthorized 
access to it. The safeguards shall provide a level of security that is at least comparable to the level of 
security described in Office of Management and Budget (OMB) Circular No. A-130, Appendix III -- 
Security of Federal Automated Systems, which sets forth guidelines for security plans for automated 
information systems in Federal agencies. The (State Licensing Agency/Certification Body Name) will not 
re-disclose QIO data to other parties within the limitations set forth in 42 CFR Part 480 unless otherwise 
approved by CMS. Data release agreements will be entered into by such other parties and CMS.  
 
V.  Channels of Communication -- QIO and State Licensing Agency/Certification Body Contacts  
 
QIO and licensing agency/certification body contact persons for oral or written communication regarding 
this data/information exchange process shall be:  
 
QIO:  
 
(Name)  
(Phone Number)  
 
Re: Memorandum of Agreement  
(Name)  
(Phone Number) 
 
State Licensing Agency/Certification Body:  
(Name)   (Phone Number)  
Re: Memorandum of Agreement  
(Name)  
(Phone Number)  
 
VI.  Amendment of Agreement  
 
This Agreement may be amended in writing by mutual agreement of the parties when required by (1) the 
Department of Health & Human Services (HHS) changes to the QIO contract; (2) QIO changes to 
operational requirements mandated by Federal law and CMS directives; (3) HHS changes in instructions or 
regulations; or (4) mutual agreement by all parties.  
 
VII.  Termination of Agreement  
 
This agreement may be terminated for any reason, upon mutual written consent of the parties with 90 days 
written notice by either party to the other, subject to applicable law and regulation. Both parties must 
provide written notice to CMS of either party's decision to terminate the agreement. 
 
 
IN WITNESS WHEREOF, The parties hereby execute this agreement:  
 
QIO: __________________________________________________________ 
  
TITLE: ________________________________________ DATE: _________  
 
STATE LICENSING AGENCY/  
CERTIFICATION BODY: ________________________________________  
 
TITLE: ________________________________________ DATE: _________ 
 
 
Exhibit 3-4 Model Joint Operating Agreement (JOA) for QIOs and Medicare 
Administrative Contractors 
(Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) 
 
A.  Agreement 
 
I.  Parties to the Agreement:   
This agreement is made by and between (MAC Name), and the (QIO Name). 
 
(MAC name) is the Medicare Administrative Contractor (MAC) for Jurisdiction (jurisdiction 
number/letter). (QIO name) is under contract with the Centers for Medicare & Medicaid 
Services (CMS) to serve as the Quality Improvement Organization (QIO) for the states of (list 
states in the QIOs jurisdiction that correspond to the MACs jurisdiction). As the QIO, (QIO 
name) is authorized to perform Medicare quality improvement activities including review as 
defined in Titles XI and XVIII of the Social Security Act. 
 
References in this agreement to federal government or similar references are intended by the 
parties to represent and to mean the United States Government, Department of Health and 
Human Services (DHHS), Centers for Medicare & Medicaid Services (CMS), Center for Clinical 
Standards and Quality (CCSQ), or any other governmental department, bureau, or section with 
which the QIO, pursuant to law or regulation, is required to have a relationship in order to carry 
out the mandate of law concerning the Medicare quality improvement and review functions 
contemplated by this agreement. 
  II.  Statutory Specifications 
QIOs are authorized to perform Medicare peer review as defined in Titles XI and XVIII of the 
Social Security Act. This authorization is made effective through the QIOs contract with CMS. 
Regulations at 42 CFR 476.80, requires a QIO to maintain a Joint Operating Agreement (JOA) 
with each Medicare Contractor processing cases it reviews. The JOA must reflect mutually 
agreeable conditions necessary for data exchange requirements in recognitions of the unique 
capabilities/requirements of each party. 
 
III.  Purpose of Agreement 
The purpose of this agreement is to set forth the operational procedures that the parties have 
agreed will be followed with respect to the review of services for which payment may be made 
under Title XVIII of the Social Security Act. This agreement is to define the relationship that will 
exist between the parties relative to exchanging information and data about CMS efforts to 
promote quality health care services for Medicare beneficiaries and to determine if services 
provided to Medicare beneficiaries are medically necessary, appropriate, and meet 
professionally recognized standards of care. 
 
It is the mutual intent of the parties to act cooperatively and to share information gained by 
either party that may be of benefit to the other. In this spirit, problems identified by either party 
will be promptly reported to and, if appropriate, acted upon by the other. It is recognized by the 
parties that peer review activities and the relation of the parties will develop and evolve during 
the period covered by this agreement. Neither party shall be required to perform duties or 
actions that are in conflict or beyond the scope of their respective contract with CMS. Where this 
agreement is in conflict with Medicare and/or CMS rules and regulations, the agreement 
provisions will be nullified until resolved by the appropriate parties. 
 
IV.  Terms of Agreement 
This agreement is effective upon execution by both parties, and will remain in effect until a new 
agreement is deemed necessary by the parties, government or until terminated. 
 
B.   Quality Improvement Organization (QIO) 
  
I.  QIO Responsibilities 
The Quality Improvement Organization (QIO) was established by CMS to improve the 
effectiveness, efficiency, economy and quality of services for Medicare beneficiaries. QIOs will 
coordinate and operate a broad range of proactive initiatives through a collaborative effort 
between QIOs and the health care community.   
 
(QIO name) is responsible for assuring that activities as well as interventions promote 
responsiveness to beneficiary and family needs; to provide opportunities for listening to and 
addressing beneficiary and family concerns; to provide resources for beneficiaries and 
caregivers in decision making, and to use information gathered from individual experiences to 
improve Medicares entire system of health care. Beneficiary-generated concerns provide an 
excellent opportunity to explore root causes, to develop alternative approaches to improving 
care, and to improve beneficiary/family experiences with the health care system. Beneficiary and 
family engagement and activation efforts are needed to produce the best possible outcomes of 
care. These QIO beneficiary and family centered efforts align with the National Quality Strategy, 
which encourages patient and family engagement. 
 
(Name of QIO) is responsible for performing the following activities in accordance with the 
terms of the Medicare QIO contract: 
 
  Include in this section information relevant to the scope of QIO reviews, claims review, 
data exchange, procedures for notification of denial and reconsideration determinations, 
and information exchange.   
It is understood the QIO review determinations may be upheld, modified, or reversed in whole or 
in part by the Secretary, his delegate, or a court acting pursuant to hearing and appeals 
procedures set forth in the Social Security Act. 
 
C.  Medicare Administrative Contractor (MAC) 
 
I.  MAC Responsibilities 
The MAC perform numerous functions to support health care services for Medicare 
beneficiaries, which include performing claims-related activities and establishing relationships 
with providers of health care services, both institutional and professional, for a defined 
geographic area or jurisdiction. 
 
The Contractor receives and controls Medicare claims from institutional and professional 
providers, suppliers, and beneficiaries within its jurisdiction and perform standard or required 
editing on these claims to determine whether the claims are complete and should be paid. 
 
The MACs are responsible for the following: 
 
1.  The MAC will review claims and make determinations on services and items for which 
payment may be made under the Social Security Act and for which the QIO has yet to 
assume responsibility. 
2.  The MAC will make determinations under Title XVIII of the beneficiary eligibility, 
reasonable provider costs and other aspects of coverage that are not specifically covered 
by this JOA but are the responsibility of the MAC.  
 
D.  Confidentiality and Disclosure 
 
The Office of Civil Rights (OCR), as the designating authority for the Health Insurance Portability and 
Accountability Act (HIPAA), has authorized  (name QIO), in its role as the QIO as a health oversight 
agency as defined in HIPAA regulations. (Name of QIO) shall adhere to the confidentiality and 
disclosure requirements set forth by 45 CFR Parts 160 and 164 as they pertain to health oversight 
agencies, as well as requirements set forth in  1160 of the Act and 42 CFR Parts 476 and 480, as well 
as confidentiality requirements under all other applicable federal statutes, federal regulations, 
applicable HIPAA regulations, and any applicable state law. 
 
None of the confidential information or any data derived from the information will be released by the 
recipient to any other organization or individual in confidential form without prior CMS approval. 
Appropriate administrative, technical, procedural, and physical safeguards shall be established by the 
recipient to protect the confidentiality of the data and to prevent unauthorized access to it. The 
safeguards shall provide a level of security that is at least comparable to the level of security described 
in the Office of Management and Budget (OMB) Circular No.  A-130, Appendix III  Security of Federal 
Automated Systems, which sets forth guidelines for security plans for automated information systems in 
federal agencies. (Name of QIO) will not redisclose QIO data to other parties within the limitations set 
forth in 42 CFR Part 480 unless otherwise approved by CMS.  Data release agreements will be entered 
into by such other parties and CMS. 
 
E.  Modification of Agreement 
 
This agreement may be amended at any time as necessary to conform with any changes of modifications 
to relevant state or federal laws or applicable regulations, transmittals, program directives, or 
instructions issues pursuant to applicable laws and regulations.  In the event of such an amendment, the 
QIO and MAC will obtain CMS approval for the revisions. 
  Minor changes to the requirements of this agreement that are necessitated by revision of the current 
federal guidelines shall be automatic and shall not require an addendum to this agreement. 
 
F.  Internal Point of Contact 
In accordance with the agreement between (QIO name) and (MAC name), the following individuals are 
designated to serve as the QIO and MAC liaison. They are responsible for notices and communications 
regarding review activity, coordination, and dissemination of such information within the agency, and 
they are to lead discussion regarding questions, needs, and suggestions regarding day-to-day 
interactions between the parties. 
 
This designation may be changed at any time by notifying the parties to this agreement in writing. 
 
 
The liaison for (QIO name) will be:  QIO COR will be: 
   
Point of Contact name  Name 
QIO Name  Address 
Address  City, State, Zip 
City, State, Zip  Phone# 
Phone #  Email address 
The liaison for (MAC name) will be:  The MAC Business Functional Liaison/COR 
  will be: 
  Point of Contact name   
  MAC Name  Jurisdiction #  Name 
  Address  Address 
  City, State, Zip  City, State, Zip 
  Phone #  Phone# 
Email address 
 
In witness whereof, the parties hereby execute this agreement by duly authorized representatives effective 
as of the last signature date below. 
 
QIO name: 
QIO Address: 
 
Signature: 
 
 
                     
(Name, Title) 
 
Date:         
 
 
MAC name: 
MAC Address: 
 
Signature: 
 
 
                     
(Name, Title) 
 
Date: