Beneficiary Complaint: QIO Review of Interim Initial Peer Review

5050.4 – Beneficiary Complaint: QIO Review of Interim Initial Peer Review Determination (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Immediately upon receipt of the Beneficiary Complaint folder from the Initial Determination Peer Reviewer, the QIO must ensure all necessary information is returned and the QRD Form has been signed. A QIO may use its discretion in providing a specific number of calendar days for review of the package to ensure the Peer Reviewer: 1. Rendered a decision on all quality of care concerns; 2. Adhered to the correct format in providing comments; and 3. Provided a rationale for conclusions that is clear, cogent and based on the available information and applicable standard of care. However, a QIO is required to have the Initial Determination Peer Review completed and the practitioner and/or provider notified of the Peer Reviewer’s Interim Initial Determination within ten (10) calendar days after the Peer Reviewer receives all medical information. NOTE: Additional procedures are applicable if the Initial Determination Peer Reviewer has: 1. Identified a concern(s) as either gross and flagrant, or 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 professionally recognized standards of health care as required by §1156(a) of the Act. o The QIO must initiate sanction proceedings in accordance with IOM Chapter 9. 2. Determined that the standard(s) of care was not met for any one or more of the concerns, and the concerns are not sanctionable. The QIO must provide notice and an opportunity for discussion to the practitioner and/or provider. See the procedures detailed in §5055, “Beneficiary Complaint: Opportunity for Discussion - Stage Three.”