Immediate Advocacy Procedures

5035.4 – Immediate Advocacy Procedures (Rev.28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Once oral consent is obtained for all parties, the QIO may either use conference call/three-way call or make a call on behalf of the beneficiary to obtain resolution of the beneficiary’s oral complaint. The focus of the call should be to provide a quick and amicable resolution of these complaints within a short time frame, such as within two (2) business days. NOTE: With the agreement to use Immediate Advocacy, a Peer Review is NOT performed. In addition, medical information should not be requested from the practitioner/provider. Practitioner and/or Provider is Unavailable/ Becomes Unavailable –In these situations, the QIO should contact the beneficiary to explain the circumstances and discuss options. In no instance should the use of Immediate Advocacy extend beyond 10 days from the initial contact with the practitioner and/or provider. Within one (1) business day following the completion of Immediate Advocacy, the QIO should update the CMS-designated case review system in accordance with the QIO contract to reflect resolution of the complaint through the use of Immediate Advocacy and close the case accordingly. While the goal of Immediate Advocacy is to informally and quickly resolve the beneficiary’s complaint, in certain instances the beneficiary might remain dissatisfied after completion of Immediate Advocacy. Should this occur, the QIO must advise the beneficiary of his/her right to file a written complaint. The QIO should also consider whether a Quality Improvement Initiative should be pursued in accordance with §5125.