Beneficiary Complaint: Reviewing Response Submitted during

5055.4 – Beneficiary Complaint: Reviewing Response Submitted during Opportunity for Discussion (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) A Final Initial Determination must be completed within three (3) business days of the discussion with the practitioner/provider and/or receipt of written statement(s). The review process must take place and be completed in an appropriate timeframe. The QIO reviews the summary of any oral response that the practitioner and/or provider has submitted, or the written Opportunity for Discussion response, in light of the quality of care concern(s) raised during the Initial Determination Peer Review. For both oral and written responses, the QIO must make every effort to highlight/summarize the specific facts the practitioner and/or provider provided during the discussion in relationship to particular elements of the standard(s) of care that could alter the Initial Determination Peer Reviewer’s Interim decision. (As noted in §5055.3, facts provided during the discussion stage cannot include new medical information). The QIO must also describe any information/rationale provided by the practitioner and/or provider that appears to be unrelated to the standard(s) of care. The QIO shall forward the information, along with specific issues identified in the response, to the Initial Determination Peer Reviewer for consideration as soon as possible after completing an oral discussion and/or receiving the written response. This ensures that the QIO adheres to the three (3)-business-day (from the date of response) timeframe for notifying the beneficiary and the practitioner and/or provider by telephone of its Final Initial Determination. NOTE: The QIO should ensure that the same Peer Reviewer renders both the Interim and/or Final Initial Determinations, unless rare circumstances exist (e.g., the Interim Initial Determination Peer Reviewer is unavailable due to serious illness). In most instances, the QIO will not be required to mail the Initial Determination Peer Reviewer the entire Beneficiary Complaint file but the Peer Reviewer should be provided with information necessary from the file to complete the Final Initial Determination. The following are best practices for completing the review process: 1. The Peer Reviewer uses the copy of the QRD Form from the Interim Initial Determination in evaluating the information the practitioner and/or provider supplied to the QIO during the Opportunity for Discussion. 2. Additional materials are usually unnecessary in situations where the practitioner and/or provider conveyed information orally directly to the Peer Reviewer. 3. The QIO and the Peer Reviewer coordinate to ensure all pertinent information is considered in the Final Initial Determination. 4. After making the Final Initial Determination, the Initial Determination Peer Reviewer re- signs the QRD Form and sends it back to the QIO. The signed form may also be faxed to expedite review. The QIO must ensure that the beneficiary and the practitioner and/or provider are informed by phone of the Peer Reviewer’s Final Initial Determination, regardless of the findings about whether the standard(s) of care were met or not met, no later than three (3) business days after the completion of its review. (See §5055.6.) • The QIO must also issue a Final Initial Determination letter to the parties within five (5) calendar days after the QIO completes its review. (See §5055.6.) NOTE: The time frame for completing review includes the Initial Determination Peer Reviewer‘s review as well as any additional review the QIO conducts after the peer review is complete (e.g., quality assurance of the Final Initial Determination letter).