Beneficiary Complaint: Preparing and Forwarding the Medicare

5040.1 – Beneficiary Complaint: Preparing and Forwarding the Medicare Quality of Care Complaint Form (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) After ending the intake call described in §5030.2, the QIO should immediately input basic information obtained during the phone call into the Medicare Quality of Care Complaint Form, except in situations where the beneficiary has requested that the form be emailed or in situations where the beneficiary expressed desire to complete the form himself or herself. NOTE: A QIO must protect confidential information under 42 CFR §480. Confidential information communicated between the QIO and the beneficiary must only be transmitted via a secure electronic submission to ensure appropriate protection of the information. Confidential information includes Personally Identifiable Information (PII) and information that would be Protected Health Information (PHI) under the HIPAA Privacy and Security Rules (45 CFR Parts 160 and 164) if the information is from a covered entity (health plan or health care provider) or if the QIO were a covered entity. A QIO is prohibited from using any independently developed complaint forms. A QIO may only use the official Medicare Quality of Care Compliant Form (CMS 10287). The QIO may direct the beneficiary to the QIO’s website or the CMS forms web page to obtain a copy of the Medicare Quality of Care Complaint Form. To assist the beneficiary in completing the Medicare Quality of Care Complaint Form, the QIO should pre-fill the following sections of the form with the information provided by the beneficiary before mailing or faxing it to the beneficiary: 1. The beneficiary’s name; 2. The beneficiary’s Medicare # (HICN); 3. The beneficiary’s sex and age (if known); 4. The beneficiary’s race/ethnicity (if the respondent is willing to provide it); 5. The name of the beneficiary’s authorized representative (if someone other than the beneficiary will be the contact); 6. The pertinent contact information, including street address and phone numbers for either the beneficiary or representative; and 7. A brief description of the complaint following the requirements of §5030.1. NOTE: The QIO can send the beneficiary complaint form by mail, fax, or email from the time the information is collected. NOTE: When the beneficiary requests the form to be sent via email, the QIO must not pre-fill the form in order to assure confidentiality. When sending the complaint form by fax, the QIO should ensure that the beneficiary is aware that the fax is being sent and that it will contain confidential information. The QIO must comply with requests from the beneficiary to not pre-fill the complaint form. Prohibition against Forwarding Additional Information: The Medicare Quality of Care Complaint Form and the Appointment of Representative Form are the only forms identified by CMS for use in the Beneficiary Complaint Review process. The QIO may forward a cover letter explaining the complaint process and any instructions for the complaint process. The QIO should not forward any additional information to the beneficiary. The QIO may only mail, fax, or email the Medicare Quality of Care Complaint Form and the Appointment of Representative Form (Appendix 5-1.2), if applicable (See the discussion of this Appointment Form in the note below). For a copy of the Medicare Quality of Care Complaint Form, see Appendix 5-1.1, “Medicare Quality of Care Complaint Form and Instructions” or visit http://www.cms.hhs.gov/cmsforms/downloads/cms10287.pdf. For a copy of the Appointment of Representative form, see Appendix 5-1.2, or visit http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf . NOTE: When a Beneficiary Representative contacts the QIO to file a complaint on behalf of a beneficiary, the QIO must question the beneficiary representative about his/her status as a “representative” of the beneficiary in order to establish that the representative has the authority to file a complaint and to receive confidential information. Return of Completed Medicare Quality of Care Complaint Form and/or the Appointment of Representative Form: • In situations where the beneficiary or beneficiary representative requests to return the completed forms by email to the QIO’s email address, the beneficiary must be advised that while returning the completed form by email is an option, the QIO is not responsible for the privacy of the beneficiary’s private health information and that doing so may not offer adequate security for protected health information. NOTE: Emailed forms or facsimiles are deemed “written” for purposes of receipt of a signed written beneficiary complaint. (See §5040.3.)