QIO Review Documentation

13110 - QIO Review Documentation (Rev. 32, Issued: 04-12-19, Effective: 05-13-19, Implementation: 05-13-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary’s Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. QIOs shall maintain file records and establish internal control systems that at a minimum enable it to perform the following functions as required under the contract: • Provide an accurate and complete record of all in-progress and completed activities, correspondence, and analyses, including a record of times and dates, in connection with every individual case review effort • Identify all individuals, roles, responsibilities, and determinations made as part of every individual case review effort • Identify all quality improvement activities in-progress and completed, to include provider/practitioner improvement plans and points of contact for each quality improvement activity • Furnish complete and accurate documentation to CMS and authorized third parties upon request • Comply with requirements for protection of all data and records in accordance with CMS security and privacy policies (see QIO Manual Chapters 8 and 10, and 42 CFR Part 480) and procedures identified in the QIO contract • Transfer to CMS, or to a successor QIO contractor as directed by CMS, any records and files, including patient medical records, necessary to perform the business functions of the QIO that are identified in the QIO contract Case Review Documentation Requirements At a minimum, QIO case review documentation must include: • Case identifiers (e.g., Medicare beneficiary identifier) • Determinations (outcomes) of each review (e.g., approval, denial, coding decision, quality concern) • Medical review criteria used in the review • Verification that appropriate review was performed • Name and title of each reviewer who contributed to the determination (e.g., review coordinator, physician advisor) • Dates of each review function that demonstrate compliance with review timeframes (e.g., date case was identified for review, dates records requested and received, dates review initiated and completed, dates notices issued, if applicable) • Any referrals to other QIOs or external agencies Denial Determinations, Diagnostic Related Group (DRG) Assignment Changes, and Confirmed Quality Concerns If the QIO determination results in an initial or technical denial, DRG assignment change, or confirmed quality concern, the review documentation must also include: • The detailed basis (e.g., all documentation already in your possession for the case) for the denial determination (including limitation on liability determinations and documentation errors), DRG assignment change, or confirmed quality concern • A copy of the notice that was sent to all parties, identification of each party, and the date the notice was mailed or delivered • The returned envelope and notice, if the notice was subsequently returned as undeliverable or receipt refused Reconsideration and/or Provider Request for a Review of a QIO DRG Determination If the QIO conducts a reconsideration or review of the QIO DRG determination, its review documentation must also include: • Documentation of the reconsideration or review request • The detailed basis for the reconsideration (including the limitation on liability determination) or review determination • A copy of the reconsideration or review determination letter that was sent to all parties, identification of each party, and the date on which the notice was mailed or delivered • The returned envelope and notice, if the notice was subsequently returned as undeliverable or receipt refused Format of QIO Case Review Documentation QIOs shall retain case review documentation in an easily retrievable format such as hard copy, electronic file record, or as specified in its contract.