General Quality of Care Review: Preparation of the Initial

5115.4 – General Quality of Care Review: Preparation of the Initial Determination Letter (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Upon receiving the QRD Form, the QIO prepares the “General Quality of Care Reviews – Initial Determination Letter” (Appendix 5-6) conveying the decision to the practitioner and/or provider. The letter must be sent to the practitioner/provider such that the practitioner/provider is notified of the initial determination within ten (10) calendar days of the receipt of medical records by the QIO (See §476.160). The letter must: • Advise the practitioner and/or provider of the right to request a reconsideration of any review initiated after July 31, 2014, if the standard(s) of care was not met for any concern(s) • Inform the practitioner and/or provider of the deadline for requesting a reconsideration (See §476.140); and • Inform the practitioner and/or provider that this will be the last communication about the QIO’s decision if no request for reconsideration is received. Note: See §5120, “General Quality of Review Reconsideration Stage Three,” for information related to a practitioner’s and/or provider’s failure to respond to the reconsideration request. If the practitioner and/or provider does not request reconsideration (by phone or in writing) within three (3) calendar days, then the practitioner and/or provider may not be granted a request for reconsideration. See §5120.