Beneficiary Complaint Intake – Stage One

5030 – Beneficiary Complaint Intake – Stage One (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) QIOs may become aware of a potential beneficiary complaint through a phone call or correspondence, including the receipt of a complaint by regular mail, email, or facsimile. The QIO is responsible for ensuring that enough information is obtained from the beneficiary to complete the review, whether Immediate Advocacy or a Beneficiary Complaint Review. It is anticipated that, in most instances, a beneficiary’s initial contact with a QIO about a potential complaint will be made by phone. QIOs may also be referred calls from 1-800 Medicare. For calls to 1-800 Medicare, once the beneficiary indicates, through answering a series of questions, that the call is regarding a complaint related to the quality of care received, the beneficiary is transferred to the appropriate QIO. CMS developed the Medicare Quality of Care Complaint Form, CMS-10287 (Complaint Form), for beneficiaries to use in submitting a complaint (See Appendix 5-1.1) (See §§5040.1-5040.3 of this Chapter for information about the use of the Complaint Form.) When a request for information from or on behalf of a beneficiary is received, the QIO must follow 42 CFR §480.132; the QIO must disclose the information to a person whom the beneficiary has identified as his/her representative or has been designated by State law. Under 42 CFR §480.132(c), if the beneficiary has not and is not able to designate a representative and State law has not designated a representative, the QIO determines who is responsible for the beneficiary and makes disclosure to that person. A beneficiary representative is either appointed by the beneficiary or authorized under applicable law. See 42 CFR §476.1. In situations where the representative does not have any evidence of his/her status, the QIO should inform the representative of the availability of the Appointment of Representative Form. The QIO can either provide the representative with a copy of the form directly or instruct them that they may obtain a copy of the form directly by visiting the CMS forms web page. See Appendix 5-1.2 or visit http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. CMS expects QIOs to concurrently enter any information received into the CMS-designated case review system (See §5030.4) so that it is readily accessible to pertinent staff.