Beneficiary Complaint: Reconsideration – Stage Four

5060 – Beneficiary Complaint: Reconsideration – Stage Four (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) For complaints filed after July 31, 2014, a Medicare beneficiary or practitioner and/or provider may request a reconsideration, in writing or by phone, within three (3) calendar days following initial oral notification of the QIO’s Final Initial Determination. A beneficiary, provider, or practitioner who is dissatisfied with the QIO’s Final Initial Determination may request reconsideration. NOTE: The Beneficiary Complaint Reconsideration Procedures (See 42 CFR §476.140) replace the Retrospective Beneficiary Complaint Re-review Process (§5250) and Concurrent Beneficiary Complaint Re-review process (§5350) provided in Manual Chapter 5 Quality of Care Revision- 17, dated 04/06/12. NOTE: §§5250 and 5350 of Manual Chapter 5 Revision – 17 dated 04/06/12 - apply to Beneficiary Complaints filed before July 31, 2014, (the date after which reconsideration rights apply pursuant to 42 CFR §476.140). (A practitioner and/or provider may request a Re-review, in accordance with Manual Chapter 5 (§§5252 and 5350) Revision-17, dated 04/06/12.) The beneficiary and/or the practitioner and/or provider may request reconsideration within three (3) calendar days of receipt of the Final Initial Determination Letter to Practitioners/ Providers (Appendix 5-4.1 and Appendix 5-4.2). The QIO s Final Decision shall be issued to the beneficiary and practitioner and/or provider no later than five (5) calendar days after the request for a reconsideration, or if later, five (5) calendar days after receiving any medical or other records needed for the reconsideration. See 42 CFR§ 476.140. NOTE: The timeframe for completion of review starts when additional information is received from all parties. If additional information is not received within seven (7) calendar days of the beneficiary or provider’s request for reconsideration, the QIO should proceed with the reconsideration with the information that is available. Upon receiving a reconsideration request, the following information must be forwarded to the reconsideration Peer Reviewer so that a reconsideration review can be completed: 1. Beneficiary Complaint folder/file 2. Quality Review Decision (QRD) Form; 3. All Medical information received; 4. Final Determination Letter to Practitioners/Providers and Beneficiaries (Appendix 5-4.1 and 5-3.2) (See §5060.3). If the Initial Determination was orally communicated to the beneficiary, the QIO should include a brief summary of the conversation; 5. Interim Initial Determination Letter for Providers/Practitioners (Appendix 5-3; 6. Information received related to the offer of the Opportunity for Discussion Stage; and 7. Any new evidence submitted in requesting the reconsideration. The package with the above information should be forwarded to the Reconsideration Peer Reviewer within one (1) business day of receiving the request for reconsideration. (See §5060.1). Reconsideration reviews must be completed within five (5) calendar days after receipt of the request for reconsideration or receipt of any medical or additional information or other records needed for the reconsideration if applicable. When a practitioner/provider fails to request a reconsideration [in cases where the concern(s) from the original beneficiary complaint are confirmed quality of care concern(s)] within three (3) calendar days following the practitioner and/or provider’s oral or written receipt of the QIO’s Final Initial Determination, the QIO will prepare and send the Final Determination Letter to the Beneficiary/Beneficiary Representative (Appendix 5-4.2). This mailing is to occur no later than five (5) calendar days after the expiration of the reconsideration period. The QIO may notify the beneficiary and the practitioner/ provider of its Final Decision by phone. However, the QIO must follow up by issuing a written notice to the parties by 12:00 noon on the next calendar day. See 42 CFR §476.140(b).