Beneficiary Complaint: Notification of Opportunity for Discussion

5055.1 – Beneficiary Complaint: Notification of Opportunity for Discussion (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) If, after reviewing the Interim Initial Peer Review Determination package, the QIO determines that the Peer Reviewer has identified a concern(s) for which the standard(s) of care was not met, the practitioner and/or provider must be offered the opportunity to discuss the concern(s). The QIO must make the effort of an offer, by telephone to the practitioner/provider to discuss the interim initial determination with the QIO in those situations where the peer reviewer determines that the quality of services does not meet professionally recognized standards of care for any concern in the complaint. The QIO should document the date on which the offer was first made to the practitioner and/or provider, and this may include sending to the practitioner and/or provider a facsimile or letter describing the specific concern(s) at issue. NOTE: A QIO must allow a practitioner to use a representative to respond to the Opportunity for Discussion. (See Appendix 5-3, “Interim Determination Letter for Practitioners or Providers”). In offering the discussion opportunity, the QIO shall make every effort to discuss the Initial Determination Peer Reviewer’s interim determination as expeditiously as possible. The time frame for obtaining a response from the practitioner and/or provider shall not extend beyond seven (7) calendar days from the date the offer was originally made. In rare circumstances (e.g., the practitioner is unavailable [out of the country] for the entire seven (7)-day period), the QIO may provide additional time to respond to the offer of a discussion or submission of a written response to the interim initial determination. The additional time should not exceed seven (7) calendar days. The practitioner and/or provider may submit a written response to the opportunity for discussion in lieu of a phone call within seven (7) calendar days of receiving the initial offer of an opportunity for discussion. • If a practitioner and/or provider requests to submit a written statement as their opportunity for discussion in addition to having a phone call, the QIO may accept both the written response and phone call discussion with the practitioner and/or provider based on the complexity of the case.