Beneficiary Complaint: Abandoned Complaints and Reopening Rights

5040.5- Beneficiary Complaint: Abandoned Complaints and Reopening Rights (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The QIO may determine that a written beneficiary complaint or the Immediate Advocacy process has been abandoned if a Medicare beneficiary fails to participate in or comply with the requirements of the Beneficiary Complaint Review process or Immediate Advocacy process and the QIO does not have enough information to complete its review. If the beneficiary no longer intends to file a written complaint, or after additional follow-up, the beneficiary fails to participate, the QIO may determine that the case has been abandoned. When a QIO determines a written complaint has been abandoned, the QIO must: 1. Inform the parties by phone that the complaint review will be discontinued and document the date of the call in the case review notes. 2. Inform the beneficiary of his/her right to resubmit a written complaint in accordance with the procedures in 42 CFR §§476.120 and 476.150(b). 3. A QIO may reopen a Medicare beneficiary complaint review using the same procedure (time period) a QIO would use for reopening initial denial determinations and changes as a result of diagnosis-related group (DRG) validation, as described in 42 CFR §476.96 (See 42 CFR § 476.150). A QIO may reopen a beneficiary complaint review within one (1) year of the date the original complaint was submitted. When a QIO determines the immediate advocacy process has been abandoned, the QIO must: 1. Inform the parties by phone that immediate advocacy has been discontinued and document the date of the call in the case review notes. 2. Inform the Medicare beneficiary of his/her right to submit a written complaint in accordance with the procedures in 42 CFR §§476.120.