Beneficiary Complaint: QIO’s Final Decision, Preparing, and Mailing

5060.3 – Beneficiary Complaint: QIO’s Final Decision, Preparing, and Mailing the Letter to Providers and/or Practitioners and the Beneficiary (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The QIO must provide notice to the beneficiary and the provider/practitioner of the reconsidered determination as soon as it is complete [i.e. within five (5) calendar days of receiving the request for reconsideration and the records for the review]. The initial notice may be done by telephone but written notice must be provided by noon the next calendar day. A QIO is NOT required to obtain consent from the practitioner and/or provider to disclose to the beneficiary the QIO’s Reconsideration Determination, the standard(s) of care at issue, whether or not the standard(s) was met, and the specific facts pertinent to the QIO in making that decision. A QIO is required to give written notice as well to the practitioner and/or provider. CMS recommends that this be done by providing a copy of the Letter to Beneficiary – Beneficiary Quality of Care Complaint: Reconsideration Determination Letter to Beneficiary (Appendix 5- 4.2) A QIO shall follow the procedures in this section for preparing the QIO’s Reconsideration Determination Letters (Appendix 5-4.1and 5-4.2). For all complaints involving practitioners or providers, the letter to the beneficiary (Appendix 5-4.2) shall include ALL of the following: 1. A statement for each quality of care concern identified where care did or did not meet the standard of care. 2. A statement defining the standard of care that the QIO identified for each quality of care concern. 3. A statement of the facts describing how the practitioner and/or 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 provider and/or practitioner met professionally recognized standards of care. 4. A statement that this constitutes the QIO’s final decision on the complaint, that no further rights are available, and there is no appeal right to the beneficiary for the applicable standard(s) of care. The QIO shall prepare and mail the Beneficiary Quality of Care Complaint: Reconsideration Determination Letter to the practitioner/provider (Appendix 5-5.1) and the Beneficiary Quality of Care Complaint: Reconsideration Determination Letter to Beneficiary (Appendix 5-5.2). A QIO shall follow the procedures in §5060.4, “Beneficiary Complaint: Procedures for Closing a Complaint Review” for closing the case in the CMS-designated case review system. A QIO may refer the practitioner/provider for, Quality Improvement Initiatives in accordance with §5125 if deemed appropriate.