Beneficiary Complaint: Quality of Care Review – Stage Two

5050 – Beneficiary Complaint: Quality of Care Review – Stage Two (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) A QIO initiates the Quality of Care Review for Beneficiary Complaint Reviews by conducting a preliminary review of the written complaint and each of the Quality of Care Concerns. For instances when the beneficiary raises multiple concerns that are potentially unrelated, the QIO shall determine whether the QIO will process the concerns as a single complaint with multiple concerns or as multiple complaints. In making this determination, the QIO should consider the following: • Number of episodes of care; • Total number of concerns; • Relationship or inter-relatedness of the concerns; • Time frames associated with the concerns; • Impact of different practitioner and/or provider involvement in each of the concerns; • Health care issues related to each of the concerns; • Beneficiary’s own statements about the relationship between the concerns; and • Other factors deemed relevant as identified by the QIO. The importance of a particular criterion may be different for different complaints, and the QIO should consider the totality of the circumstances. Consultation with other QIO personnel who have been involved or reviewed the materials is recommended when appropriate for making the determination to separate complaints that have been uploaded into the CMS-designated case review system as a single complaint. If a decision is made to process concerns as separate complaints, notice of the QIO determination under §476.130(d) must include the rationale for that decision. Further, the rationale must be included in the CMS-designated case review system files.