General Quality of Care Review: Preparing and Mailing the Final

5120.3 – General Quality of Care Review: Preparing and Mailing the Final Reconsideration Determination Letter (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) In preparing the General Quality of Care Reviews: Final Reconsideration Determination Letter to Providers and Practitioners (See Appendix 5-7), the QIO must ensure the letter includes the following: 1. A statement for each quality of care concern that care did or did not meet the standard(s) of care; 2. The standard(s) that the QIO identified for each quality of care concern; 3. A specific statement conveying facts describing how the practitioner and/or provider did or did not meet specific criteria within the standard; and 4. A statement that this constitutes the QIO’s final decision and that no further appeal rights are available. The QIO’s Final Decision shall be issued to the provider no later than five (5) calendar days after the request for reconsideration, or if later, five (5) calendar days after receiving any medical or other records needed for the reconsideration. See 42 CFR §476.170. NOTE: The timeframe for completion starts when additional information is received from all parties. If additional information is not received within seven (7) calendar days of the offer to submit additional information, the QIO should proceed with the reconsideration with the information that is available.