General Quality of Care Review: Requesting Medical Information

5110.2 – General Quality of Care Review: Requesting Medical Information (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The following steps do not apply to instances where the QIO already possesses medical information (e.g. records in connection with another review activity). The instructions and guidance here are written to apply to requests for medical information in response to General Quality of Care Reviews conducted as a result of referrals and/or tracking and trending of data. TIMELINE: Practitioners and/or providers are obligated to forward all required information within fourteen (14) calendar days of the request from a QIO. See 42 CFR §476.160(b). A QIO may request the medical information from the practitioner and/or provider sooner than the fourteen (14)- calendar day time frame, if the QIO determines the review involves a potential gross and flagrant or substantial violation of the quality of care and circumstances warrant earlier receipt of the information. If the QIO makes a preliminary determination that the review involves a potential gross and flagrant violation or a substantial quality of care concern as specified in Part 1004 of the Act, and circumstances warrant earlier receipt of the medical information, the QIO should document the determination and the reason for it. Medicare health plans (MHPs) are responsible for submitting medical information absent a specific delegation to the provider. Should a MHP fail to submit medical information as requested within the prescribed fourteen (14)-calendar-day timeframe (or at an earlier date as applicable, the matter should also be referred to the pertinent CMS COR for CMS to take action to secure compliance by the Medicare health plan. When a provider has been specifically delegated the responsibility to submit medical information, the COR will collaborate with the Division of Medicare Health Plan Operations (DMHPO) about any options that may be pursued in light of the provider’s Medicare Provider Agreement. In situations where a practitioner and/or provider fails to submit medical information within the required time frame, the practitioner and/or provider may be subject to a denial of payment under 42 CFR §476.90. In some situations, where either a practitioner or provider fails to submit medical information within the required timeframe, the QIO should advise the practitioner or provider that, based on §1156(a)(3), sanctions may be initiated because of the failure to support the provision of items or services with evidence of the medical necessity for and quality of the items or services. NOTE: Upon receiving medical information at any step, follow the instructions as outlined in §5110.4, “General Quality Review: Review and Preparation of Medical Information.” CMS expects the QIO to complete the following steps in requesting medical information consistent with 42 CFR 476.160(b): Step 1: Request the medical information within one (1) business day after receiving the referral or identifying a potential quality of care concern as a result of tracking and/or trending of data. The QIO may contact the practitioner and/or provider by phone and follow up with a facsimile or mailed letter. If a letter is sent, the letter must clearly indicate the specific date on which the medical information was first requested, because this date will be used to determine when a claim denial shall be issued. See §5110.3 for information about a claim denial. Even if a letter is not sent, the QIO must document the date and time of the request. NOTE: The date of the letter may be used if it corresponds to the date of the first request. The QIO must advise a practitioner and/or provider of the requirement to submit the requested medical information within fourteen applicable time frame. A QIO may contact either/both the Medical Records Department or the QIO liaison based on procedures that have been established with the practitioner and/or provider. Step 2: The QIO should follow up as necessary to ensure adherence to the fourteen (14) calendar-day submission deadline - i.e. fourteen (14) calendar days from request or the earlier in those circumstances where the QIO made a preliminary determination that the review involved a potential gross and flagrant or substantial quality of care concern. Before making contact to follow up on the request for information and documents, the QIO should verify the following information: 1. The QIO has not previously requested and received the medical information by conducting a search in the CMS-designated case review system. 2. The date the medical record is due for receipt by the QIO is correct. The timeframe can vary in cases where a potential gross and flagrant quality of care concern is identified. If the medical information is not received from the practitioner and/or provider by calendar day fourteen (14) or other date the QIO designates, the QIO will notify the practitioner and/or provider of potential for denial of the applicable claim(s) under 42 CFR §476.90; and Remind the practitioner/provider that , under §1156(a)(3), items or services provided by or ordered by practitioners must be supported by evidence of medical necessity and quality, in such form and fashion and at such time as may reasonably be required by a QIO in the exercise of its duties and responsibilities. The QIO should point out that any unreasonable delay in providing medical information could lead to sanctions under §1156(b). This step is meant to furnish a practitioner and/or provider with adequate notice to correct any problems associated with submitting medical information, and to help the practitioner and/or provider avoid potential penalties or claims denials. Step 3: In addition to contacting the provider /practitioner, the QIO should immediately contact the COR and provide sufficient information so that the COR is prepared to contact the practitioner and/or provider. The QIO should also follow up with the COR to advise him/her if/when the medical information is received. Step 4: On the next business day after the deadline for the delivery of the medical information requested by the QIO, the COR may call the Medical Records Department, the QIO liaison, and/or senior leadership, and convey the responsibilities associated with the request for the medical information. The COR may assess the willingness of the practitioner/provider to comply with the request for medical information and explain the potential repercussions of failure to provide the medical information, including: • A claim denial; • For Medicare health and drug plans, notifying the Division of Medicare Health Plan Operations; and • Referral to the OIG. NOTE: The COR advises that if the medical information is not received within the next calendar day, a claim denial shall be carried out for any claim associated with the quality of care concern identified. Step 5: If the medical information is not received from a practitioner and/or provider within thirty (30) calendar day of the QIO request, the QIO must proceed in accordance with §5110.3, “General Quality Review: Issuing a Claim Denial.” NOTE: In instances when the QIO completes a claim denial, the practitioner and/or provider is still required to comply with its responsibility to forward the medical information to the QIO to complete the quality of care review. For providers and practitioners, a COR may recommend additional action depending on the particular facts of the situation (e.g., recommending that the QIO conduct additional Quality of Care Reviews on other patients for whom the practitioner and/or provider has submitted similar claims for payment).