September 11, 2018
Quality Improvement Organizations (QIOs) Determination Letter
When a QIO identifies improper payments, they notify the provider via a determination letter (also referred to as a results letter). They also notify CGS to initiate the overpayment process. Once CGS is notified, the claim is adjusted and a remittance advice and overpayment demand letter is generated. At this time, if you disagree with the QIO decision, you may request a redetermination (first level of appeal) within 120 days from the date of the CGS demand letter or remittance advice. It is not appropriate to request an appeal upon receipt of the QIO determination letter and prior to the claim adjustment.
If a provider decides to appeal the denial decision, they must wait until the CGS demand letter or remittance advice is received. An appeal request cannot be processed prior to the demand letter being issued.