Beneficiary Complaint: Forwarding the Complaint to the QIO

5045.1 – Beneficiary Complaint: Forwarding the Complaint to the QIO (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The Beneficiary Complaint is identified as awaiting review in the CMS-designated case review system once the intake process and subsequent entry into the system is completed. Once the Beneficiary Complaint is identified as awaiting review, the QIO: 1. Reviews the Medicare Quality of Care Complaint Form and information in the CMS- designated case review system to ensure that he/she understands the specific concern(s) involved. This includes those instances when multiple concerns have been raised, whether the concerns relate to a single complaint or multiple complaints. 2. Contacts the beneficiary to orally acknowledge receipt of the complaint, CMS expects within one (1) business day of receiving the complaint. During the discussion with the beneficiary, the QIO should obtain additional information (if necessary) and describe/explain the following to the beneficiary: 1. The complaint process to the beneficiary in more detail; 2. His or her role; 3. The Initial Determination Peer Reviewer’s role; 4. The Peer Review process in general; and 5. The anticipated time frames related to the resolution of the review. If the QIO is unable to reach the beneficiary by phone, the QIO should follow up with the beneficiary within five (5) business days from the date of the initial call attempts. The QIO should initiate the review immediately, even in those instances when the beneficiary cannot be immediately contacted, unless information necessary for completing the review is still needed. If the QIO is unable to reach the beneficiary by phone, he/she should contact the beneficiary by letter, advising the beneficiary that a review cannot be conducted until the necessary information is received. NOTE: If the QIO is unable to collect the additional information from the beneficiary by calendar day thirty (30), contact the beneficiary on calendar day thirty-one (31)(or the next business day) and advise the beneficiary that the case will be closed.