Beneficiary Complaint: Receipt and Review by the Initial

5050.3 – Beneficiary Complaint: Receipt and Review by the Initial Determination Peer Reviewer (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The QIO mails or sends the package via a secure electronic method to the Initial Determination Peer Reviewer immediately after receiving the Medical Record documentation. Once the Peer Reviewer receives the medical record documentation, he/she should immediately initiate the review. The Peer Reviewer must review the Quality of Care Concern(s) identified by the beneficiary and any additional concern(s) identified by the QIO. After the Peer Reviewer receives all the medical record documentation, the QIO has ten (10) calendar days to ensure that the Initial Determination Peer Reviewer completes the following steps: 1. Completes the review; 2. Notifies the practitioner and/or provider of the Initial Determination Peer Reviewer’s Interim Initial Determination; and 3. Notifies the practitioner/provider of the opportunity to discuss the Determination. (See 42 CFR 476.130(c).) NOTE: The QIO is responsible for ensuring that the Interim Initial Determination is completed within ten (10) calendar-days of receipt of the medical information. This includes the following: Peer Reviewer renders an Interim Initial Determination The practitioner/provider is notified of the Interim Initial Determination and is provided with the opportunity to discuss, within the required ten (10)-calendar-day time frame (See §5050.3.) The discussion must occur within seven (7) calendar days of the notice to the practitioner/provider. Initial Determination Peer Review Approach For Individual Concerns – The Peer Reviewer evaluates the standard(s) that the QIO identified on the QRD Form and checks off the appropriate box indicating whether he/she concurs or does not concur with the standard(s) of care as delineated by the QIO. • If the Peer Reviewer identifies quality of care concerns not raised by the beneficiary or identified by the QIO, the Peer Reviewer must indicate this and identify pertinent research describing the standard of care he/she used to identify and evaluate the concern. • If the Peer Reviewer determines that the standard(s) that the QIO identified for a specific concern(s) is incorrect or not appropriately thorough, the Peer Reviewer must identify the correct standard(s) and provide an explanation about the change. • For instances when the Peer Reviewer determines that the standard(s) is incorrect, the Peer Reviewer must include a rationale, with references to relevant literature/research and/or medical information supporting his/her decision on the appropriate standard(s) of care in the QRD Form. The Peer Reviewer then applies the standard(s) of care to the specific facts of the case and the Quality of Care Concern(s) at issue. The Peer Reviewer evaluates the medical information based on the standard(s) as identified, including each evidenced-based element of the standard(s) of care. For a complete and adequate peer review, CMS expects each Peer Reviewer to: 1. Evaluate whether the quality of care standard for each identified concern is met based on the facts of the case and directly link his/her decisions to elements contained in the evidence-based standard(s), or in the absence of evidence-based standards of care, will use available norms, best practices, and established guidelines. 2. Assess the responsibility of the individual identified by the beneficiary to determine if the individual identified is different from the individual who is responsible for the standard(s) not being met. 3. Consider any historical data pertinent to the concern as provided by the QIO, and highlight specific evidence from the review of the medical information demonstrating that specific elements within the standard(s) of care are or are not met. NOTE: The Peer Reviewer should also include any other information that the reviewer deems relevant to the Interim Initial Determination. If the Peer Reviewer concludes that there are extenuating circumstances to consider (e.g., emergent circumstances or exceptional complexity), the Peer Reviewer must thoroughly explain these and how they are relevant to the Interim Initial Determination. After completing the Rationale/Justification portion for each concern on the QRD Form, the Peer Reviewer must identify (and document), by checking off the appropriate box, whether the standard(s) of care was met or was not met for each concern. This decision/determination must be based on the analysis and justification. If the Peer Reviewer determines that the standard of care was not met for a concern, the Peer Reviewer must also check off the appropriate box indicating whether any of the following findings is also present: 1. The care grossly and flagrantly violated the practitioner/provider’s obligation to provide care, in one or more instances, that is of a quality that meets the professionally recognized standards. 2. The care failed in a substantial number of cases (more than three) to substantially comply with the obligation to provide care that is of a quality that meets the professionally recognized standards. 3. The care failed to substantially comply with the obligation to provide care that is of a quality that meets the professionally recognized standards. 4. The care was not a substantial failure of a quality that meets the professionally recognized standards, but was a significant concern. 5. The care did not meet the standard of care, but was less than a substantial violation of the obligation to provide care that is of a quality that meets the professionally recognized standard. The Initial Determination Peer Reviewer must complete the review of the medical information, completely and accurately fill out the QRD Form to document the determination review thoroughly, and return the review package to the QIO in the agreed upon timeframes. The Peer Reviewer must sign and date the QRD Form and indicate the amount of time spent reviewing the complaint. Except in circumstances when the Peer Reviewer conducts the review on the QIO premises or electronically through a secure site, the reviewer may maintain a signed copy of the completed QRD Form and additional copies of notes in a secure location. These may be maintained by the Peer Reviewer to facilitate any additional review necessary based on the receipt of additional information during the Opportunity for Discussion Stage.