---
kind: "range"
citation: "42 C.F.R. §§ 475.101–475.103"
title: "42"
from: "475.101"
to: "475.103"
count: 3
url: "https://uscodex.org/cfr/42/475.101..475.103"
---

# §475.101. Eligibility requirements for QIO contracts.


In order to be eligible for a QIO contract, an organization must meet the following requirements:

- (a) Have a governing body that includes at least one individual who is a representative of health care providers and at least one individual who is a representative of consumers.
- (b) **Demonstrate the ability to perform the functions of a QIO, including—**
  - (1) The ability to meet the eligibility requirements and perform activities as set forth in the QIO Request for Proposal; and
  - (2) **The ability to—**
    - (i) Perform case reviews as described in [§ 475.102](/cfr/42/475.102.md); and/or
    - (ii) Perform quality improvement initiatives as set forth in [§ 475.103](/cfr/42/475.103.md).
- (c) Demonstrate the ability to actively engage beneficiaries, families, and consumers, as applicable, in case reviews as set forth in [§ 475.102](/cfr/42/475.102.md), and/or quality improvement initiatives as set forth in [§ 475.103](/cfr/42/475.103.md).
- (d) Demonstrate the ability to perform the functions of a QIO with objectivity and impartiality and in a fair and neutral manner.

# §475.102. Requirements for performing case reviews.

- (a) In determining whether or not an organization has demonstrated the ability to perform case review, CMS will take into consideration factors such as:
  - (1) The organization's proposed processes, capabilities, quantitative, and/or qualitative performance objectives and methodology to perform case reviews;
  - (2) The organization's proposed involvement of and access to physicians and practitioners in the QIO area with the appropriate expertise and specialization in the areas of health care related to case reviews;
  - (3) The organization's ability to take into consideration urban versus rural, local, and regional characteristics in the health care setting where the care under review was provided;
  - (4) The organization's ability to take into consideration evidence-based national clinical guidelines and professionally recognized standards of care; and
  - (5) **The organization's access to qualified information technology (IT) expertise.**
- (b) In making determinations under this section, CMS may consider characteristics such as the organization's geographic location and size. CMS may also consider prior experience in health care quality improvement that CMS considers relevant to performing case reviews; such prior experience may include prior similar case review experience.
- (c) A State government that administers a Medicaid program will be considered incapable of performing case review in an effective manner, unless the State demonstrates to the satisfaction of CMS that the State agency performing the case review will act with complete objectivity and independence from the Medicaid program.

# §475.103. Requirements for performing quality improvement initiatives.

- (a) In determining whether or not an organization has demonstrated the ability to perform quality improvement initiatives, CMS will take into consideration factors such as:
  - (1) The organization's proposed processes, capabilities, quantitative, and/or qualitative performance objectives, and methodology to perform quality improvement initiatives;
  - (2) The organization's proposed involvement of and access to physicians and practitioners in the QIO area with the appropriate expertise and specialization in the areas of health care concerning the quality improvement initiatives;
  - (3) The organization's access to professionals with appropriate knowledge of quality improvement methodologies and practices; and
  - (4) **The organization's access to qualified information technology (IT) expertise.**
- (b) In making determinations under this section, CMS may consider characteristics such as the organization's geographic location and size. CMS may also consider prior experience in health care quality improvement that CMS considers relevant to performing quality improvement initiatives; such prior experience may include prior similar quality improvement initiative experience and whether it achieved successful results.
- (c) A State government that administers a Medicaid program will be considered incapable of performing quality improvement initiative functions in an effective manner, unless the State demonstrates to the satisfaction of CMS that the State agency performing the quality improvement initiatives will act with complete objectivity and independence from the Medicaid program.