Beneficiary Complaint: Preparing the Final Determination Letter to

5055.6 – Beneficiary Complaint: Preparing the Final Determination Letter to Practitioners/Providers and Beneficiaries (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The QIO shall follow the procedures in this Section for preparing the QIO’s Final Determination Letters (Appendix 5-4.1 and 5-4.2). Upon receiving the QRD Form, the QIO prepares the Final Determination Letter to Practitioners/Providers (Appendix 5-4.1) and Beneficiaries (Appendix 5-4.2) conveying the decision to the practitioner and/or provider, and advising the practitioner and/or provider and the beneficiary of the right to request a reconsideration within three (3) calendar days. The QIO should: • No later than 3 business days after completion of the review or end of the discussion period notify (by telephone) the beneficiary and the practitioner/provider of the Final Initial Determination and of the right to request a reconsideration of the QIO's Final Initial Determination; and • Mail the Final Determination Letter to Practitioners/Providers (Appendix 5-4.1) and to the beneficiary (Appendix 5-4.2) within five (5) calendar days of completion of the review. NOTE: If the determination is provided by telephone on the third business day and the fifth calendar day falls on the same day, the letter should be mailed by 12:00 noon on the next business day. See 42 CFR §476.130(d) (2). The written notice to providers and practitioners must include: • A statement for each concern that care did or did not meet the standard of care; • The standard identified by the QIO for each of the concerns; and • A summary of the specific facts that the QIO determines are pertinent to its findings, including references to medical information and, if held, the discussion with the involved practitioner and/or provider. For all complaints involving providers or practitioners, the letter to the beneficiary (Appendix 5- 4.2) shall include at least ALL of the following: 1. A statement for each quality of care concern identified in the original written complaint and whether care did or did not meet the standard of care. NOTE: This does not include other quality of care concerns identified by the QIO during the course of review. 2. A statement defining the standard of care that the QIO identified for each quality of care concern raised by the beneficiary. 3. A statement of the facts describing how the practitioner/provider did or did not meet the standard of care. The statement of facts should relate only to the facts that were essential in determining whether a practitioner and/or provider met professionally recognized standards of care. In the Final Initial Determination Letter for complaints filed after July 31, 2014, a QIO must also inform the beneficiary if the QIO receives a request for reconsideration from any of the parties, the results of the QIO’s Final Initial Determination could change. The QIO should also inform the beneficiary that if/when a reconsideration is requested and reviewed, the beneficiary will receive a QIO Final Decision letter (See Appendix 5-5.2 Reconsideration Determination Letter to the Beneficiary) at a later date (See §5060.3 for issuance of the QIOs Final Decision).