General Quality of Care Review: Reviewing and Preparing Medical

5110.4 – General Quality of Care Review: Reviewing and Preparing Medical Information (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Upon receiving the medical record documentation, the QIO should immediately date-stamp the form and scan the form, original envelope, and/or facsimile, or email and upload them to the CMS-designated case review system (unless received electronically). The QIO should file the original envelope with the medical record documentation. The QIO should also ensure that all information in the medical information is complete, appropriately organized, and legible. If the medical documentation in the medical record is incomplete or illegible (poor copy), the QIO may contact the practitioner and/or provider by phone and allow an additional five (5) calendar days for submission of the documentation necessary to complete the medical review process. NOTE: QIOs should follow the procedures for issuing a claim denial in §5110.3 when complete medical information is not received in accordance with the timeline identified in §5110.2 (See Appendix 5-10, “General Quality of Care Review - Best Practices”) The QIO should verify that the medical information record documentation received for each medical request contains the major documentation components, particularly those relevant to the quality of care concern. Examples include but are not limited to the following: 1. Emergency Room Record/Admission Record; 2. History and Physical; 3. Consultations; 4. Practitioner Orders; 5. Practitioner Progress Notes; 6. Nursing Notes; 7. Ancillary (e.g., laboratory Reports, X-rays, medication administration record, treatment administration record) 8. Discharge Summary. NOTE: QIOs are authorized to upload medical record documentation received directly into the CMS-designated system or other secure electronic system(s) CMS approves. The documentation should be uploaded within one (1) business day of receiving the medical information. For General Quality of Care Reviews, the following communication information should be documented in the CMS-designated case review system: • Date on which a QIO requests medical records from a practitioner and/or provider by phone, in writing, fax, or CMS approved method for secure file transfer. • Date on which a practitioner and/or provider contacts the QIO (in writing, by phone or in person) to request a reconsideration. • Date and pertinent parts of the conversation when the QIO notifies the practitioner and/or provider of the QIO’s Final Decision, which must occur within five (5) calendar days after the request for reconsideration or receipt of the medical or other records needed for the reconsideration. (NOTE: If the QIO orally contacts the practitioner/provider about this decision, the QIO must send the practitioner/provider a written notice by 12:00 noon of the next calendar day.) Use of the CMS-designated case review system is designed to facilitate the resolution of any questions that may arise about a specific complaint and ensures that all pertinent information related to a complaint is uniformly recorded and centrally located in the CMS-designated case review system. If the QIO or Peer Reviewer determines that handwritten information in the medical information cannot be deciphered, the QIO may contact the facility and request a typed/transcribed portion of the problem sections of the medical information. The QIO should make every effort to limit the amount of typed/transcribed information requested. Failure to comply with a request for typed/transcribed information shall be treated as a failure to provide the medical information if the missing information precludes the completion of the review. The Initial Determination Peer Reviewer may be consulted before determining to pursue a claim denial. QIOs must follow the procedures in §5110.3 for processing these denials.