Beneficiary Complaint: Requesting Medical Information

5045.2 – Beneficiary Complaint: Requesting Medical Information (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The QIO determines the date(s) of the episode(s) of care concerning the beneficiary complaint to ensure that the complaint is eligible for Beneficiary Complaint Review. Under §476.120, a beneficiary complaint must be filed within 3 years of the episode of care out of which the complaint arises. If the complaint has been timely filed, the QIO should request medical information as soon as the written complaint is received with sufficient information to identify the practitioner and/or provider. (See §5030.2.) Timely requests should happen no later than one (1) business day after receipt of the complaint (See - Medical Record Request Key Process). Upon request by a QIO, a practitioner and/or provider must deliver all medical information requested within fourteen (14) calendar days of the request. NOTE: The QIO may request the provider submit the information sooner than fourteen (14) days if there is a preliminary determination that the complaint involves a potential gross and flagrant or substantial quality of care concern as specified in Part 1004 of the Act, and circumstances warrant earlier receipt of the medical information. See 42 CFR §476.130 (b)(1). For significant complaints, the QIO should request medical information as soon as sufficient information has been obtained to identify the pertinent practitioners and providers. For details about a QIO’s right to request medical information, see 42 CFR §476.78(b)(2), “Review Responsibilities of Quality Improvement Organizations – Responsibilities of Health Care Facilities,” and 42 CFR §480.111(a), “QIO Access to Records and Information of Institutions and Practitioners.” Practitioners/Providers must be informed that they are expected to provide information within the fourteen (14)-calendar-day timeframe, that the request is the result of a beneficiary’s complaint, and of the right to discuss the QIO’s interim initial determination. The QIO must also request the name of a contact person to ensure timely completion of any discussion. Failure to Provide the Medical Record Requested: The following paragraphs describe when a Medicare Health Plan or the practitioner/provider is responsible for the medical record submission and the steps the QIO must take for CMS to investigate or take enforcement action as a result of the failure to provide information when the requested medical information is not received. In situations in which a practitioner/provider fails to submit medical information within the required fourteen (14)-calendar-day time frame, the practitioner/provider may be subject to a denial of payment under 42 CFR §476.90. In some situations where either a practitioner and/or provider fails to submit medical information within the required fourteen (14)-calendar-day time frame, the QIO should advise the practitioner and/or provider that, based on §1156(a)(3), sanctions may be initiated because of the failure to support the provision of items or services with evidence of medical necessity and quality as may be required. (See Manual Chapter 9, “Sanction, Emergency Medical Treatment and Labor Act (EMTALA), and Fraud and Abuse” for information on initiating a sanction process). NOTE: Upon receiving the beneficiary’s medical information at any step, follow the instructions as outlined in §5045.4, “Beneficiary Complaint: Review and Preparation of Medical Information.” Medical Record Request - Key Process Steps CMS expects the QIO to complete the following steps in requesting medical records and \information: Step 1: Request the medical information within one (1) business day of receiving the written complaint. The QIO may contact the practitioner and/or provider by phone and follow up with a facsimile or mailed letter. CMS expects the letter clearly indicate the specific date on which the medical information was first requested since this date will be used to determine when a claim denial shall be issued for a practitioner/provider. See §5045.3 for information about issuing a claim denial. A QIO may contact either/both the Medical Records Department or the QIO liaison based on procedures established with a practitioner and/or provider. A QIO may obtain the medical information from the practitioner and/or provider via facsimile, hard copy, or a secure electronic method when available. The QIO should remain aware of its responsibility to protect confidentiality of information at all times when arranging to receive medical information. Step 2: A QIO should follow up as necessary to ensure adherence to the requested submission deadline—i.e., fourteen (14) calendar days from request or earlier in those circumstances where the QIO made a preliminary determination that the complaint involved a potential gross and flagrant or substantial quality of care concern. Before making contact, the QIO should verify that: 1. The QIO has not previously requested and received the medical information by conducting a search in the CMS-designated case review system. 2. The date the medical record is due for receipt by the QIO is correct. The timeframe can vary in cases where a potential gross and flagrant quality of care concern is identified. Step 3: If the medical information is NOT received from the practitioner/provider by calendar day fourteen (14) or other date designated by the QIO, contact the practitioner’s/provider’s senior leadership and notify the provider of the consequences for failure to provide documents under 42 CFR §476.90. If the medical information is NOT received from a practitioner/provider by calendar day fourteen (14) or other date designated by the QIO, contact and remind the practitioner/provider, under §1156(a)(3), items or services provided by or ordered by practitioners/providers must be supported by evidence of medical necessity and quality, in such form and fashion and at such time as may reasonably be required by a QIO in the exercise of its duties and responsibilities. The QIO should point out that any unreasonable delay in providing medical information could lead to sanctions under §1156(b). Step 4: CMS expects and best practices support that the QIO contact the CMS COR when a practitioner/provider has failed to submit a medical record within the designated timeframes. In addition to contacting the practitioner/provider, the QIO should immediately contact the COR and provide sufficient information so that the COR is prepared to contact the practitioner and/or provider. The QIO should also follow up with the COR to advise if/when the medical information is received. The COR will call the Medical Records Department, the QIO liaison, and/or senior leadership, and convey the responsibilities associated with the request for the medical information on the next business day after calendar day fourteen (14) (or the next business day after the date established by the QIO when there’s been a preliminary determination by the QIO of potential gross and flagrant or substantial quality of care concern). The COR will assess the willingness to comply with the request for medical information and explain the potential repercussions of failure to provide the medical information, including: • Issuing a claim denial; • Notifying the Division of Medicare Health Plans Operations; and • Potential for the QIO to conduct additional reviews. NOTE: The COR will advise the contact that if the medical information is not received within the next calendar day, a claim denial shall be carried out for any claim associated with the care described in the complaint. Step 5: If the medical information is not received from a provider by the next business day following calendar day fourteen (14) (or the next business day after the date established by the QIO), proceed in accordance with §5045.3, “Beneficiary Complaint: Issuing a Claim Denial.” NOTE: In instances where the QIO completes a claim denial in accordance with §5045.3 the provider is still required to comply with its responsibility to forward the medical information to the QIO for them to complete the Quality of Care Review. For practitioners and providers, a COR may recommend additional action depending on the particular facts of the situation (e.g., recommending that the QIO conduct additional Quality of Care Reviews on other patients for whom similar claims have been submitted for payment by the practitioner and/or provider). In instances where the requested medical information is not received within thirty (30) calendar days from the date of request, the beneficiary is still entitled to notice of the outcome of the review under §476.130(d); however, the specific information should be tailored to the situation rather than listing the information identified in §476.130(d). The beneficiary must be advised in writing and provided with the following information: • The QIO is unable to complete the review as a result of the practitioner’s and/or provider’s failure to submit the medical information. • For complaints related to practitioners and/or providers: CMS has initiated action to deny Medicare payment to the provider for the services surrounding the care referenced in the beneficiary’s complaint. • Based on §1156(a)(3), sanctions may be initiated against a practitioner and/or provider for failing to support the items or services they have provided with evidence of the quality of the items or services. In instances where the medical information is received within the next thirty (30) calendar days, the beneficiary should be contacted and advised that the review will be completed.