Beneficiary Complaint Review Protocols

5040 – Beneficiary Complaint Review Protocols (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) These are the key decision points in determining whether to proceed with a Beneficiary Complaint and/or a General Quality of Care Review upon completion of the Intake Process: • Immediate Advocacy was appropriate, but the beneficiary expressed the intent to file a written complaint. • Immediate Advocacy was not appropriate, and the beneficiary expressed the intent to file a written complaint. • Immediate Advocacy is not appropriate because an oral beneficiary complaint involved at least one concern that is significant, substantial, or gross and flagrant, and the beneficiary does not wish to submit the oral complaint in writing. When a QIO receives an oral complaint, where it finds concern(s) that may be significant, the QIO is authorized to perform a General Quality of Care Review of the services related to that concern. (See §5100 General Quality of Care Reviews). • Neither Immediate Advocacy nor the written beneficiary complaint processes are available options because the beneficiary wishes to remain anonymous. Oral and written complaints where the beneficiary wishes to remain anonymous can be processed at General Quality of Care Reviews if a quality of care concern is at least a significant one or if the QIO deems a General Quality of Care Review appropriate under 42 CFR §476.160. (See §5100 General Quality of Care Reviews).