General Quality of Care Review: Return of Initial Determination

5115.3 – General Quality of Care Review: Return of Initial Determination (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Immediately upon receiving the General Quality of Care Review folder from the Initial Determination Peer Reviewer, the QIO must ensure all necessary information has been returned and the QRD Form has been signed. The QIO should review the QIO Form to ensure that the Peer Reviewer rendered a decision on all quality of care concerns, that the content adheres to the correct format, and that the rationale for conclusions is clear. This review should occur promptly to ensure that the mandatory timeframe for notifying the practitioner/provider is met. The QIO must ensure that the practitioner and/or provider is notified of the Peer Reviewer’s Initial Determination, in writing, within 10 calendar days from receipt of a complete medical record. In the same letter in which the QIO informs the practitioner/provider of the Initial Determination results, the QIO must also notify the practitioner/provider of his/her right to request reconsideration for reviews initiated after July 31, 2014. NOTE: If the Initial Determination Peer Reviewer has identified a concern(s) as either gross or flagrant, or 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 (see §1156(a) of the Act), then the QIO must initiate sanction proceedings in accordance with Manual Chapter 9. Once confirming that the documentation is complete for the Initial Determination Peer Reviewer’s determination as to whether the standard of care was met or was not met for all concerns, the QIO should follow the procedures detailed in §5115.4, “General Quality of Care Review: Preparation of the Initial Determination Letter”