Quality of Care Reviews – General

5070 – Quality of Care Reviews – General (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The following sections provide instructions for QIOs to follow in reviewing quality of care concerns received and/or identified from sources other than Beneficiary Complaints. (See 42 CFR §476.160. These sources include: 1. Concerns Identified during Other Review Activities: Quality of Care reviews conducted when a potential quality of care concern(s) is identified during any other review activity (e.g., medical necessity reviews, expedited discharge appeals, Emergency Medical Treatment and Labor Act (EMTALA) reviews. See § 5075, “Concerns Identified during Other Review Activities.” 2. Referrals: Quality of care reviews conducted in response to referrals from other entities (e.g., contractors, state-based organizations, the Office of Inspector General, the Office for Civil Rights), and anonymous referrals. See §5080, “Source – Anonymous Beneficiary” and §5085, “Referrals.” 3. Tracking and Trending: Quality of Care reviews conducted as a result of tracking and trending of data. See §5095, “Tracking and Trending of Data.” The process instructions are identical for reviews that originate from sources other than Beneficiary Complaints (i.e., Concerns Identified during Other Review Activities, Referrals, or Tracking and Trending). (See §§5100-5100.4.) Unlike Beneficiary Complaint Reviews, where the instructions are divided into four stages, General Quality of Care Review is grouped into three stages to help identify roles and steps associated with various aspects of the process. The General Quality of Care Review stages are as follows: Stage One: Intake Stage Two: Quality of Care Review Stage Three: Reconsideration