Beneficiary Complaint: Reviewing and Preparing Medical Information

5045.4 – Beneficiary Complaint: Reviewing and Preparing Medical Information (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Receipt of Medical Record Documentation/Information: Upon receiving the medical record documentation, the QIO should immediately date-stamp the form and scan the form, original envelope, and/or facsimile or email. These documents should be uploaded to the CMS- designated case review system (unless received electronically) within one (1) business day. The QIO must file the original envelope with the medical record documentation in a hard copy file or as a scan of the documents for storage in an electronic file. Medical Documentation Completeness and Organization: The QIO ensures all information in the medical information is complete, appropriately organized, and legible. If the medical documentation in the medical record is incomplete or illegible (poor copy), the QIO may contact the practitioner and/or provider by phone and allow an additional five (5) calendar days for submission of the documentation necessary to complete the medical information needed for review. NOTE: QIOs must follow the procedures for issuing claims denials in §5045.3 when complete medical record documentation is not received in accordance with the fourteen (14) calendar-day timeframe. The QIO should verify that the medical record documentation received for each medical record request contains the major documentation components. Examples include but are not limited to the following: 1. Emergency Room Record/Admission Record; 2. History and Physical; 3. Consultations; 4. Practitioner Orders; 5. Practitioner Progress Notes; 6. Nursing Notes; 7. Ancillary (e.g., laboratory reports, X-rays, medication administration record, treatment); 8. Miscellaneous; and 9. Discharge Summary. NOTE: QIOs are authorized to upload medical record documentation received directly into the CMS-designated system or into a secure electronic system that CMS otherwise designates or approves. The documentation should be uploaded within one (1) business day of receiving the medical information. If the QIO staff member preparing the case for review and/or Physician Peer Reviewer(s) determine that handwritten information in the medical information cannot be deciphered, the QIO may contact the provider and/or practitioner and request a typed/transcribed portion of the problem sections of the medical information. A QIO should make every effort to limit the amount of typed/transcribed information requested. Failure to comply with a request for typed/transcribed information shall be treated as a failure to provide the medical information if the missing information precludes the completion of the review. QIOs must follow the procedures in §5045.3 for processing a claim denial when applicable.