Timeframes For Retaining QIO Review Documentation

13115 - Timeframes For Retaining QIO Review Documentation (Rev. 23, Issued: 12-03-15, Effective: 12-03-15, Implementation; 12-03-15) Retain copies of all case review documentation as follows: Approved Reviews Retain all review documentation for 12 months from the date review is completed. Approved reviews, as used in this instruction, refer to initial reviews of medical necessity, quality, or appropriateness of healthcare services conducted by a QIO review associate and/or a physician peer reviewer in which there are no confirmed issues at the completion of the reviews identified in 42 CFR 476.71. Negative Determinations In accordance with regulations at 42 CFR 476.94(e), retain all review documentation of initial denial determinations and DRG assignment changes for six years from the date the services in question are furnished. In addition, retain all review documentation of confirmed quality concerns for six years from the date the services in question are furnished. DRG Review Determinations Retain all review documentation of DRG assignment change review determinations, including re-reviews, for six years from the date the services in question are furnished. Reconsideration Determinations In accordance with regulations at 42 CFR 478.36, retain all review documentation of reconsideration determinations for four years after the date on the notice of the QIO’s reconsidered determination, or until litigation is completed and the time period for filing all appeals has passed, whichever is later. Audits Ensure that the documentation is readily retrievable within 10 working days for any auditing process that may be required by CMS. If an audit is conducted by CMS, retain all review documentation for three years from the date of the audit or the timeframes for retaining documentation specified in this Manual, whichever is later.