Use of CMS-Designated Case Review System

5030.4 – Use of CMS-Designated Case Review System (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) QIOs have an obligation under §1154(a)(9) of the Act to collect and maintain all information that is necessary to perform their functions. In order to ensure that information is maintained and available to CMS (see 42 CFR 480.130), QIOs are required under their contracts to use the CMS-designated case review system to record all data/information collected for all written and oral complaints, including complaints handled through the Immediate Advocacy process. This applies to any information the beneficiary provides during the initial intake of the complaint, including a thorough description of the complaint, any notes obtained during the intake process or other individuals involved in processing the complaint, and the names of staff inputting information in the CMS-designated case review system. This data collection process is designed to help resolve any questions that may arise about a specific complaint and ensures that all pertinent information related to a complaint is uniformly recorded and centrally located in the CMS-designated case review system. Any oral communication between the QIO, the beneficiary, the QIO, and the practitioner and/or providers should be documented in the CMS-designated case review system. For Beneficiary Complaints, oral communication information should be documented in the CMS-designated case review system. In addition, CMS will use the documentation in the system to review and ensure that QIO work in this area is consistent with the applicable law and that beneficiaries, providers, and practitioners are provided the review and reconsideration rights to which they are entitled. For complaints deemed appropriate for Immediate Advocacy, the following information should be collected and entered in the CMS-designated case review system: • Date that consent is obtained from the parties to participate in the Immediate Advocacy process; • Pertinent parts of the conversation between the QIO and the beneficiary during the Immediate Advocacy process; and • Date of phone conversation that led to discontinuation of the Immediate Advocacy process and the outcome of the Immediate Advocacy process. For written Beneficiary Complaints, the following information should be collected and entered in the CMS-designated case review system: • Date(s) the QIO requests medical records or other pertinent information from the practitioner/provider by phone, in writing, fax, or CMS approved method for secure file transfer in order to conduct a Peer Review; • Pertinent parts of the phone (or in-person) conversation between the QIO and the practitioner and/or provider when the QIO orally communicated their Interim Initial Determination; • QIO’s phone (or in-person) conversation with the beneficiary and the practitioner/provider when the QIO orally communicated the QIO’s Final Initial Determination; • Date the beneficiary and practitioner/provider exercised his/her right to request a reconsideration by notifying the QIO orally; • Date of the phone call (or in-person conversation) and pertinent content of the oral communication when the QIO notified the beneficiary and practitioner/provider of the QIO’s Final Decision; • Date of the oral conversation between the QIO and the beneficiary when the QIO informed the beneficiary of his/her right to resubmit a written complaint after the complaint has been abandoned; and • Date the beneficiary orally contacted the QIO about a complaint when the beneficiary does not submit a written Complaint Form by calendar day 31 or advises the QIO during the initial discussion that s/he will not submit a written complaint. (See §5210.2.) For Abandoned Complaints: If the QIO could not complete its review because the beneficiary failed to participate or comply with the complaint review process, then the date of the notice from the QIO to the beneficiary and the practitioner/provider informing the parties the complaint has been abandoned, including the reason why the QIO believes the complaint has been abandoned, should be documented. Such notice may be oral or in writing. For abandoned complaints that the QIO subsequently refers for a General Quality of Care Review, refer to §§5100 -5120 for further instructions: NOTE: Use of the CMS-designated case review system is designed to facilitate the resolution of any questions that may arise about a specific complaint and ensures that all pertinent information related to a complaint is uniformly recorded and centrally located in the CMS- designated case review system.