Beneficiary Complaint: Oral or Written Response by

5055.2 – Beneficiary Complaint: Oral or Written Response by Practitioner/Provider - Opportunity for Discussion (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Personnel The offer of the Opportunity for Discussion can be made by the QIO, the Initial Determination Peer Reviewer, or the Medical Director, depending on the QIO’s established practice. However, the QIO should participate in discussions between the Initial Determination Peer Reviewer and the practitioner/provider to handle any administrative questions or issues that arise during this discussion. For complex cases, it is recommended that the Medical Director participate. Processing Responses Oral Responses: The QIO must prepare a summary of any oral response submitted to document that the discussion occurred. During the oral discussion, the practitioner and/or provider should be advised of the need to focus on the specific element(s) of the standard(s) of care or the care provided to the beneficiary that is being disputed in the Initial Determination Peer Reviewer’s Interim Determination. Written Responses: The practitioner and/or provider should be advised of the need to focus on the Initial Determination Peer Reviewer’s conclusions related to specific elements of the standard(s) of care. Written statements submitted for the Opportunity for Discussion must be sent to the QIO for processing and properly documenting the review file for the Peer Reviewer.