General Quality of Care of Care Review: Reconsideration – Stage Three

5120 – General Quality of Care of Care Review: Reconsideration – Stage Three (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The General Quality of Care Reconsideration procedures (see 42 CFR §476.170) replaces the Retrospective General Quality Re-review Process (§5580) and Concurrent General Quality Re- review Process (§5640) described in Manual Chapter 5 Quality of Care Revision-17, dated 04/06/12. NOTE: For General Quality of Care Re-Reviews filed before July 31, 2014, (see 42 CFR §476.170), a practitioner and/or provider may request a Re-review, in accordance with Manual Chapter 5, (§s 5640 and 5580) Revision-17, dated 04/06/12. For Re-reviews filed after July 31, 2014, a practitioner and/or provider may request reconsideration in accordance with §476.170. For General Quality of Care Reviews filed after July 31, 2014, the practitioner and/or provider may request reconsideration within three (3) calendar days of receiving the QIO’s Final Initial Determination (i.e. General Quality of Care Reviews: Initial Determination Letter with Right to Request Reconsideration to Practitioner and Providers - Appendix 5-6). Additional evidence may also be submitted as part of the reconsideration process. Upon receiving a reconsideration request, the QIO must forward the General Quality of Care Review folder including the following items to the Reconsideration Peer Reviewer so that a reconsideration review can be completed: • QRD form; • All medical information received by the QIO; • General Quality of Care Reviews: Initial Determination Letter with Right to Request Reconsideration to Practitioners and Providers, which conveys the decision to the practitioner and/or provider (Appendix 5-6); and • Any new evidence submitted in requesting the reconsideration. The folder with the above information should be forwarded to the Reconsideration Peer Reviewer as soon as possible as the reconsideration decision must be provided within 5 calendar days (See §5120.1).