Eligibility for Immediate Advocacy

5035.2 – Eligibility for Immediate Advocacy (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) A QIO may offer Immediate Advocacy to the beneficiary prior to obtaining a written beneficiary complaint when the following criteria are met: 1. After initially screening the complaint, the QIO determines the complaint was received within six (6) months from the date of service on which the care occurred concerning the complaints and: a. The beneficiary complains about a matter that is unrelated to the clinical quality of health care itself but relates to items and/or services that accompany or are incidental to the medical care and are provided by a practitioner and/or provider (e.g., beneficiary in search of or needing an intervention for resources and/or services covered by Medicare, such as a wheelchair that was not delivered, a beneficiary concerned about the quality of communication with their practitioner and/or provider); or b. The beneficiary complains about a matter that, while related to the clinical quality of health care the beneficiary received, does not rise to the level of being a “gross and flagrant,” “substantial,” or “serious or urgent” quality of care concern. This may include situations where the QIO determines that the medical information will most likely not contain evidence related to the complaint. NOTE: A complaint is not eligible for Immediate Advocacy when the beneficiary has multiple concerns and the QIO determines that at least one of the concerns is “gross and flagrant,” “substantial,” or “significant.” 2. The beneficiary AGREES to the disclosure of his/her name. See 42 CFR §476.110 (a)(3). 3. All parties orally consent to the use of Immediate Advocacy. See 42 CFR §476.110 (a)(4). 4. All parties agree to the limitations on redisclosure; namely, all communications, written and oral, exchanged during the Immediate Advocacy process must not be redisclosed without the written consent of all parties.( See 42 CFR §§476.110 (c) and 480.107) The following examples of complaints are appropriate for Immediate Advocacy: • The beneficiary complains that the practitioner spoke to him/her in a rude manner or otherwise did not treat him/her respectfully. • The beneficiary contacts the QIO about his/her failure to receive a motorized scooter or wheelchair. • The beneficiary is concerned that he/she received a different colored pill than expected and would like the QIO to call the facility to find out what drug was given.