General Quality of Care Review: Receipt and Review by the Initial

5115.2 – General Quality of Care Review: Receipt and Review by the Initial Determination Peer Reviewer (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The QIO mails or sends the materials to be reviewed and the QRD Form via a secure electronic method to the Initial Determination Peer Reviewer immediately after receiving the Medical Record documentation. Once the Peer Reviewer receives the medical record documentation, the review should be initiated immediately. The Peer Reviewer evaluates the standard(s) that the QIO identified for each concern on the QRD Form and checks off the appropriate box indicating whether he/she concurs or does not concur with the identified standard(s) of care. If the Peer Reviewer identifies new Quality of Care Concerns, the Peer Reviewer must identify and document the concern(s), as well as the specific standard(s) of care for each concern, and include pertinent research supporting the standard of care he/she used to evaluate each concern on the QRD form. If the Initial Determination Peer Reviewer determines that the standard(s) identified by the QIO for a specific concern(s) is incorrect or not thorough, he/she identifies the correct standard(s) and provides an explanation of the change, including references to relevant literature/research supporting his/her decision on the appropriate standard(s) of care. The Initial Determination Peer Reviewer then applies the standard(s) of care to the specific facts of the case and the Quality of Care Concern(s) at issue. The Peer Reviewer evaluates the medical information based on the standard(s) as identified, including each evidenced-based element of the standard(s) of care. The Peer Reviewer must evaluate whether the quality of care standard for each identified concern is met based on the facts of the case and directly link his/her decisions to elements contained in the evidence-based standard(s), or in the absence of evidence-based standards of care, using available norms, best practices, and established guidelines consistent with §476.100. The Peer Reviewer also assesses the individual who is responsible for any standard(s) not met. The Peer Reviewer addresses the following in the documentation of the Review: • Any historical data pertinent to the concern(s) provided by the QIO, highlighting specific evidence from the review of the medical information and demonstrating specific elements within the standard(s) of care that are met or not met; • Any other information relevant to the Initial Determination; and • Extenuating circumstances taken (or not) into consideration (e.g., emergent circumstances or exceptional complexity). NOTE: The Peer Reviewer must be accurate and thorough in conducting and documenting the review, including a full explanation of the analysis, in order to fulfill the Review responsibility. Upon completing the Rationale/Justification portion for each concern on the QRD Form, the Initial Determination Peer Reviewer must check off the appropriate box indicating his/her decision that the standard(s) of care was met or not met for each concern. If the Peer Reviewer determines that the standard(s) of care was not met for a concern, the Initial Determination Peer Reviewer must also check off the appropriate box indicating whether: • The care grossly and flagrantly, in one or more instances, violated the provider’s or practitioner’s obligation to provide care that is of a quality that meets professionally recognized standards of health care. • The care failed in a substantial number of cases (more than three) to substantially comply with the obligation to provide care that is of a quality that meets the professionally recognized standard(s) of health care. • The care failed to substantially comply with the obligation to provide care that is of a quality that meets the professionally recognized standard(s) of health care. • The care did not meet the standard of care, but was less than a substantial violation of the obligation to provide care that is of a quality that meets the professionally recognized standard(s) of health care (i.e., it was either significant or non-significant). The Initial Determination Peer Reviewer must complete the review of the medical information provided and complete the QRD Form (See Appendix 5-1.3). The peer reviewer must, adhere strictly to the format in the QRD Form, and return the completed QRD Form to the QIO in sufficient time that the practitioner/provider can be notified of the initial determination within ten (10) calendar days of the QIO receiving the necessary medical records. The Peer Reviewer must sign and date the QRD Form and indicate the amount of time spent reviewing the materials. Except in circumstances when the Peer Reviewer conducts the review on the QIO premises, the Peer Reviewer may maintain a signed copy of his/her completed QRD Form and additional notes.