Reporting Results of System-wide Change Quality Improvement

5125.2.9 – Reporting Results of System-wide Change Quality Improvement Initiatives (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Pursuant to their contracts, Quality Innovation Network QIOs must report system-wide changes due to Quality Improvement Initiatives (QIIs) to CMS. Attribution of the improvements to the specific interventions that the QIO identified and/or in consultation with the practitioner and/or provider is an integral part System-wide Change Quality Improvement Initiatives. Documented improvement is required and is defined as any amount of quantitative improvement in a process or outcome related to the quality of care concern that is attributable to the QIO’s activity. In reporting the system-wide change under the contract, QIOs must document the problem, define interventions as implemented by the provider(s) and/or practitioner(s), identify goals of the change, and describe the evaluation methodology. NOTE: QIOs may include additional information if necessary to demonstrate the success of the QII. A Quality Innovation Network-QIO should work with its COR to determine the best method for ensuring continuous progress related to successful completion of system-wide changes, including determining when the System-wide Change Report must be uploaded into the CMS-designated case review system. A QII is deemed “completed” once the pertinent period of data collection has been fulfilled, and the QIO is able to demonstrate that the goals of the system-wide change have been attained. Pursuant to its contract, a Quality Innovation Network-QIO shall submit a report, in accordance with agreed-upon timeframes with the COR, that describes progress on the initiation, development, implementation, and conclusion for each QII. The report shall identify successful interventions (e.g., tools and resources) used in each QII. In addition, the report shall include the details of any unsuccessful QIIs based on the unwillingness of practitioner(s) and/or provider(s) to participate or instances when the QIO decided not to initiate a QII. A representative from the QIO shall be prepared to discuss the progress of their QII efforts with the COR on an as-needed basis. Appendix Appendix 5-1.1 – Medicare Quality of Care Complaint Form (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Medicare QUALITY OF CARE COMPLAINT FORM Information to Help You Fill Out the “Quality of Care Complaint” Form The Medicare Program works to ensure that beneficiaries get the best care possible. We take your concern(s) seriously, and we would like to get more information to help us review your request. Use of this form will ensure that we process your concerns in an efficient manner. Quality Improvement Organizations (QIOs), are under contract with Medicare and are required to conduct reviews of all written complaints from beneficiaries about the quality of services not meeting professionally recognized standards of health care. You may contact the QIO for assistance in completing this form or for general assistance regarding your complaint. Please use this step‐by‐step instruction sheet when completing your “Quality of Care Complaint” Form. Be sure to complete all sections of the form. In addition, if your personal information has been included in the form based on contact you have had with the QIO for your State, please review the information to confirm its accuracy. 1. Print the name of the Medicare beneficiary who has a complaint about the quality of health care he/she received. 2. Include the Beneficiary’s Medicare (HICN) number if known. 3. Check the appropriate box designating the sex of the individual listed in number 1. In addition, please indicate the age of the beneficiary in the blank space provided, if known. 4. Check the appropriate box or boxes indicating the race/ethnicity of the individual listed in number 1. Please note that this information is strictly voluntary and has no impact on the processing of the complaint. 5. Print the name of the beneficiary’s authorized representative if someone other than the beneficiary will be the contact for the processing of the complaint. 6. Print the contact information for the beneficiary or for the beneficiary’s authorized representative who is authorized to be the contact for the processing of the complaint. 7. Provide a brief description of the incident or concern. The description should include any information you believe is relevant to the review of your complaint, including: • Dates and times, • Identification of physicians and provider staff involved, • Information from witnesses if available, and • A description of what happened; and • If you require more space to describe your complaint, you may attach additional sheets of paper and you may provide any documents you believe support your complaint. PLEASE NOTE: If you raise concerns that are not quality of care concerns within the scope of the QIO’s authority, your complaint will be referred to the appropriate entity. 1. By signing the form, you are authorizing the QIO to review your complaint and render a formal determination. The processing of your complaint may require requesting and reviewing of pertinent medical records. 2. PLEASE keep this page for your information. Only mail the second page (Medicare Quality of Care Complaint Form) to the QIO. The phone number of your QIO is ______________. A decision on your complaint will be made within ___ days of receiving the signed complaint form. Form CMS-10287 (Revised 07/14) MEDICARE QUALITY OF CARE COMPLAINT FORM 1. Beneficiary Name: 2. Medicare # (HICN): 3. Sex: Male__ Female__ Age: ____ Date of Birth:_____ 4. Race/Ethnicity (Completion of this section is voluntary): How would you describe your race? Please mark one or more boxes. American Indian or Alaska Native___ Native Hawaiian or Other Pacific Islander __ White__ Asian __ Black or African American__ Hispanic or Latino___ 5. Beneficiary’s Authorized Representative’s Name (If applicable): 6. Contact Information: Street/Apt. City: State: Zip: Phone: Alternate Phone: 7. Briefly Describe the incident or your concerns: Include dates and times, persons involved, and description of what happened. Include attachments, if appropriate. 8. May we reveal your identity during the review of your complaint? Yes__ No __ If you check “no” we cannot review your complaint as a written beneficiary complaint. However, based on the circumstances of your complaint, we may choose to review your complaint as a general quality of care review. You will not receive any information or notice about a general quality of care review if the QIO chooses to perform one. 9. Check “yes” here if you authorize the QIO to forward your address or other contact information to the entity that conducts beneficiary satisfaction surveys. If you check “yes”, you will be contacted by telephone or postal mail to conduct a brief survey about your satisfaction with the service you received from the QIO. If you leave this question blank, a surveyor will contact you about your satisfaction. Yes___ No___ For your information: If you have any questions about your complaint, please call _________________. You will be contacted within ___ days upon the QIO’s receipt of the signed complaint form. The QIO will use a physician who practices in the same or similar clinical area as the physician who provided your care in completing its review. You may provide any information you believe is relevant to your complaint, including copies of documentation, names of witnesses, etc. A decision will be made on your complaint within ___ days of receiving the signed complaint form. If your complaint includes concerns not within the scope of the QIO’s authority, the concerns will be referred to the appropriate entity. 10. By signing this form, I am requesting that the QIO review my complaint. Signature of Beneficiary/Representative: Date: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1102. The time required to prepare and distribute this collection is 10 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850 Form CMS-10287 (Revised 07/14) Appendix 5-1.2 – Appointment of Representative Form (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved OMB No.0938-0950 CENTERS FOR MEDICARE & MEDICAID SERVICES APPOINTMENT OF REPRESENTATIVE Section 1: Appointment of Representative To be completed by the party seeking representation (i.e., the Medicare beneficiary, the provider or the supplier): I appoint this individual, to act as my representative in connection with my claim or asserted right under Title XVIII of the Social Security Act (the “Act”) and related provisions of Title XI of the Act. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my appeal, wholly in my stead. I understand that personal medical information related to my appeal may be disclosed to the representative indicated below. Signature of Party Seeking Representation Date Street Address Phone Number (with Area Code) City State Zip Code Section 2: Acceptance of Appointment To be completed by the representative: I, ,hereby accept the above appointment. I certify that I have not been disqualified, suspended, or prohibited from practice before the Department of Health and Human Services (DHHS); that I am not, as a current or former employee of the United States, disqualified from acting as the party’s representative; and that I recognize that any fee may be subject to review and approval by the Secretary. I am a / an (Professional status or relationship to the party, e.g. attorney, relative, etc.) Signature of Representative Date Street Address Phone Number (with Area Code) City State Zip Code Section 3: Waiver of Fee for Representation Instructions: This section must be completed if the representative is required to, or chooses to waive their fee for representation. (Note that providers or suppliers that are representing a beneficiary and furnished the items or services may not charge a fee for representation and must complete this section.) I waive my right to charge and collect a fee for representing before the Secretary of DHHS. Section 4: Waiver of Payment for Items or Services at Issue Instructions: Providers or suppliers serving as a representative for a beneficiary to whom they provided items or services must complete this section if the appeal involves a question of liability under section 1879(a)(2) of the Act. (Section 1879(a)(2) generally addresses whether a provider/supplier or beneficiary did not know, or could not reasonably be expected to know, that the items or services at issue would not be covered by Medicare.) I waive my right to collect payment from the beneficiary for the items or services at issue in this appeal if a determination of liability under §1879(a)(2) of the Act is at issue. Charging of Fees for Representing Beneficiaries before the Secretary of DHHS An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with an appeal before the Secretary of DHHS (i.e., an Administrative Law Judge (ALJ) hearing, Medicare Appeals Council review, or a proceeding before an ALJ or the Medicare Appeals Council as a result of a remand from federal district court) is required to obtain approval of the fee in accordance with 42 CFR 405.910(f). The form, “Petition to Obtain Representative Fee” elicits the information required for a fee petition. It should be completed by the representative and filed with the request for ALJ hearing or request for Medicare Appeals Council review. Approval of a representative’s fee is not required if: (1) the appellant being represented is a provider or supplier; (2) the fee is for services rendered in an official capacity such as that of legal guardian, committee, or similar court appointed representative and the court has approved the fee in question; (3) the fee is for representation of a beneficiary in a proceeding in federal district court; or (4) the fee is for representation of a beneficiary in a redetermination or reconsideration. If the representative wishes to waive a fee, he or she may do so. Section III on the front of this form can be used for that purpose. In some instances, as indicated on the form, the fee must be waived for representation. Approval of Fee The requirement for the approval of fees ensures that a representative will receive fair value for the services performed before DHHS on behalf of a beneficiary, and provides the beneficiary with a measure of security that the fees are determined to be reasonable. In approving a requested fee, the ALJ or Medicare Appeals Council will consider the nature and type of services rendered, the complexity of the case, the level of skill and competence required in rendition of the services, the amount of time spent on the case, the results achieved, the level of administrative review to which the representative carried the appeal and the amount of the fee requested by the representative. Conflict of Interest Sections 203, 205 and 207 of Title XVIII of the United States Code make it a criminal offense for certain officers, employees and former officers and employees of the United States to render certain services in matters affecting the Government or to aid or assist in the prosecution of claims against the United States. Individuals with a conflict of interest are excluded from being representatives of beneficiaries before DHHS. Where to Send This Form Send this form to the same location where you are sending (or have already sent) your: appeal if you are filing an appeal, grievance if you are filing a grievance, initial determination or decision if you are requesting an initial determination or decision. If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227). TTY users please call 1-877- 486-2048. CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 0950. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Appendix 5-1.3 – Quality Review Decision (QRD) Form (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Quality Review Decision (QRD) Form Case Summary Case ID#: State: Choose a State Patient Details Patient Name: HIC#: Date of Birth: Click here to enter a Date of Birth. Date QRD Created: Enter QRD Created date. Date of Death:Click here to enter a Date of Death. Beneficiary Point of View: Health Service Encounter Provider/Practitioner Name: Provider CCN: Service Start Date: Click here to enter Service Start Date Provider/Practitioner NPI: Service End Date: Click here to enter Service End Date. Reason for Health Service Encounter/Admitting Diagnosis: Case Summary Notes: Review Details Review Analyst: Review Due Date: Review Analyst Assessment Please note that the information below must be prepared for each Quality of Care (QoC) Concern identified in the complaint Case ID#: QoC Concern #: Concern Summary Concern Category: ____________________ Improvement may be needed in: _________ Quality of Care Concern Identified by: Source: Practitioners involved: Name: NPI: Relevant Standard of Care: Standard of Care Category: Standard of Care Source: Standard of Care Publication Date: Additional Information: Initial Determination Peer Review Case ID#: QoC Concern #: Conclusion: ☐Standard of Care Met ☐Standard of Care Not Met ☐Grossly and flagrantly violated the obligation in §1156(a)(2) of the Act, in one or more instances, to provide care that is of a quality that meets professionally recognized standards (Sanction Activity Required) ☐Failed in a substantial number of cases (more than three) to substantially comply with the obligation in §1156(a)(2) of the Act, to provide care that is of a quality that meets professionally recognized standards (Sanction Activity Required) ☐Substantial failure to comply with the obligation in §1156(a)(2) of the Act to provide care that is of a quality that meets professionally recognized standards (Quality Improvement Initiative recommended; consider referral for technical assistance with QII) ☐Significant concern (Quality Improvement Initiative recommended; consider referral for technical assistance with QII) ☐Non-significant concern (Quality Improvement Initiative recommended; QIO to consider offering advice or an alternative approach or education) Agree with QIO Identified Standard of Care: ☐ Agree ☐ Do Not Agree ☐ Concern Identified by IDPR Reason for Disagreement: Relevant Standard of Care: Standard of Care Category: Standard of Care Source: Standard of Care Date: Rationale/Justification: Conflict of Interest Statement: I do not have a material, professional, familial, or financial conflict of interest regarding any parties associated with this case including any referring entity, any health benefits plan, the patient or his/her family, the care providers, the facility, or the developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended (prescribed) or provided; nor have I accepted compensation for my independent review activities that is dependent in any way on the specific outcome of the case or had involvement with the case prior to its referral to independent review. Initial Determination Peer Reviewer Name (print): __________________________________________ Initial Determination Peer Reviewer Signature: ___________________________________________ Date: Minutes Spent on Case: Final Initial Determination Peer Review Case ID#: QoC Concern #: Written Response Received from practitioner and/or provider: Relationship of Information to Standard of Care: Conclusion: ☐Standard of Care Met ☐Standard of Care Not Met ☐Grossly and flagrantly violated the obligation in §1156(a)(2) of the Act, in one or more instances, to provide care that is of a quality that meets professionally recognized standards (Sanction Activity Required) ☐Failed in a substantial number of cases (more than three) to substantially comply with the obligation in §1156(a)(2) of the Act, to provide care that is of a quality that meets professionally recognized standards (Sanction Activity Required) ☐Substantial failure to comply with the obligation in §1156(a)(2) of the Act to provide care that is of a quality that meets professionally recognized standards (Quality Improvement Initiative recommended; consider referral for technical assistance with QII) ☐Significant concern (Quality Improvement Initiative recommended; consider referral for technical assistance with QII) ☐Non-significant concern (Quality Improvement Initiative recommended; QIO to consider offering advice or an alternative approach or education) Rationale/Justification: Conflict of Interest Statement: I do not have a material, professional, familial, or financial conflict of interest regarding any parties associated with this case including any referring entity, any health benefits plan, the patient or his/her family, the care providers, the facility, or the developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended (prescribed) or provided; nor have I accepted compensation for my independent review activities that is dependent in any way on the specific outcome of the case or had involvement with the case prior to its referral to independent review. Initial Determination Peer Reviewer Name: __________________________________________ Initial Determination Peer Reviewer Signature: ___________________________________________ Date: Minutes Spent on Case: Reconsideration Peer Review Case ID#: QoC Concern #: Written Reconsideration Request Received from practitioner and/or provider: Click here to enter received date. Conclusion: ☐Standard of Care Met ☐Standard of Care Not Met ☐Grossly and flagrantly violated the obligation in §1156(a)(2) of the Act, in one or more instances, to provide care that is of a quality that meets professionally recognized standards (Sanction Activity Required) ☐Failed in a substantial number of cases (more than three) to substantially comply with the obligation in §1156(a)(2) of the Act, to provide care that is of a quality that meets professionally recognized standards (Sanction Activity Required) ☐Substantial failure to comply with the obligation in §1156(a)(2) of the Act to provide care that is of a quality that meets professionally recognized standards (Quality Improvement Initiative recommended; consider referral for technical assistance with QII) ☐Significant concern (Quality Improvement Initiative recommended; consider referral for technical assistance with QII) ☐Non-significant concern (Quality Improvement Initiative recommended; QIO to consider offering advice or an alternative approach or education) Rationale/Justification: Agree with QIO Identified Standard of Care: ☐ Agree ☐ Do Not Agree ☐ Concern Identified by RPR Reason for Disagreement: Relevant Standard of Care: Standard of Care Category: Standard of Care Source: Standard of Care Date: Conflict of Interest Statement: I do not have a material, professional, familial, or financial conflict of interest regarding any parties associated with this case including any referring entity, any health benefits plan, the patient or his/her family, the care providers, the facility, or the developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended (prescribed) or provided; nor have I accepted compensation for my independent review activities that is dependent in any way on the specific outcome of the case or had involvement with the case prior to its referral to independent review. Reconsideration Peer Reviewer Name: __________________________________________ Reconsideration Peer Reviewer Signature: ___________________________________________ Date: __ Minutes Spent on Case: _______________________________________________________________________ Appendix 5-2 – Beneficiary Quality of Care Complaint: Initial Acknowledgement Letter to Beneficiary/Beneficiary Representative (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) QIO LETTERHEAD INITIAL NOTIFICATION Date of Notice Name of Addressee Address City, State, and Zip Code Beneficiary Name Medicare # (HICN) Practitioner/Provider Name Practitioner/Provider Number (CCN/NPI/UPN) Date(s) of Service Dear [insert name of Beneficiary/ or Representative here]: We have received your written quality of care complaint(s). Thank you for taking the time to bring your health care concern(s) to our attention. [Insert QIO name here] is the Beneficiary and Family Centered Care Quality Improvement Organization (QIO) authorized by the Centers for Medicare & Medicaid Services (CMS) to review medical services provided to people with Medicare in [Insert QIO area/region here]. As part of our mission, we review all written complaints about the health care that was provided by a physician and/or facility to people with Medicare. The goal of our review is to determine if that care was appropriate and followed acceptable medical standards. Our review is based on what is written in the medical record but is not limited to your specific complaints. During the review, we may find other concerns about the care you received. You will get our result(s) in writing when the review is completed. These are examples of the types of factors we can review in a medical record: • Was your medical condition diagnosed correctly? • Did you get the right medication for your medical problem? • Did the doctor perform the right surgery? • Was the care given to you by the staff done correctly? Our review process does not address issues such as billing, customer service, communication, legal, or any other issues that are not noted in the medical record. We understand that these issues are important, but our quality of care review is limited to the medical care reflected in the entries in the medical record. If a quality of care concern is identified, we offer education and feedback to providers to improve the quality of care for people with Medicare. The following is a summary of the concerns identified in your written complaint. Summary of Concern(s) What the Medicare Complaint Process CAN Address This first section of the summary letter contains the parts of your complaint(s) that can be addressed by a review of the medical record. NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN THE LETTER. PREPARATION NOTE FOR THE QIO The summary must include the specific concerns identified by the beneficiary and any concerns identified by the QIO based on the initial intake analysis. (See § 5110.1) This information should be consistent with the information contained in the QRD Form. (See §5230.2)] What the Medicare Complaint Process CANNOT Address This second section of the summary letter contains any part of your complaint(s) that may be related to customer service, billing, legal, or other issues that cannot be addressed by a review of the medical record. NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN THE LETTER. PREPARATION NOTE FOR THE QIO The summary must include the specific concerns identified by the beneficiary and any concerns identified by the QIO based on the initial intake analysis. (See §5110.1) This information should be consistent with the information contained in the QRD Form. (See §5230.2)] We want to make sure that we clearly understand your quality of care concerns. Please feel free to contact us with any questions or comments you may have. [Insert QIO Name] [Insert QIO Contact Person] [Insert QIO Address] [Insert QIO Contact Number] [Insert QIO Fax Number] It is important to let you know that the actual time needed to complete our review will depend on the time needed to obtain the necessary medical records and responses from the practitioner(s)/provider(s) involved. If there are any delays in the process, we will contact you. Once again, thank you for bringing your concerns to our attention. Sincerely, Medical Director (or designated physician) [Insert title here] Appendix 5-3 – Beneficiary Quality of Care Complaint: Interim Determination Letter for Practitioners and Providers (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) NOTE: This letter is optional since the Interim Determination can be given to Providers/Practitioners via phone and/or in writing. (See §5055.1) QIO LETTERHEAD Date of Notice QIO Liaison for Provider or Practitioner’s Name Name of Addressee Address City, State, and Zip Code Beneficiary Name Medicare # (HICN) Practitioner/Provider Name Practitioner/Provider Number (CCN/NPI/UPN) Date(s) of Service Dear: [insert name of Practitioner or Provider here] The [Insert QIO name here] is the Quality Improvement Organization (QIO) authorized by the Centers for Medicare & Medicaid Services (CMS) to review medical services provided to Medicare beneficiaries in [Insert QIO area/region here]. One of the functions we perform is the review of health care provided to Medicare beneficiaries to determine if the care provided was consistent with professionally recognized standards of health care, normally referred to as a Quality of Care Review. QIOs conduct these reviews to investigate complaints initiated by beneficiaries or the patients’ representatives about the health care they received. In addition, Quality of Care Reviews may be performed as a result of other tasks that CMS assigns to the QIO. Opportunity for Discussion As part of the review process, we are required to give you an opportunity to discuss our initial findings before we make our final decision. Your response can be written or oral and must be received within 7 calendar days from the receipt of this letter in order for us to consider information you provide in our Final Determination. Please be advised that this is not an opportunity for you to submit additional medical information. If additional medical information is submitted, we will not consider it in rendering the Final Determination. However, we welcome any policies, guidelines, rationale, and/or evidence-based information you would like us to consider in the review. Summary of Findings A QIO Peer Reviewer has reviewed the care provided to [Insert name of beneficiary who has consented here] by [name of practitioner] or at [name of provider]. Based on an evaluation of the information received, the following is the summary of our review. Confirmed and/or identified concern(s): NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN LETTER PREPARATION NOTE FOR QIO The summary must include: • The specific concerns identified by the beneficiary and any concerns identified by the QIO based on the Scope of Review (See §5110.1), • The standard of care associated with each concern, • A statement of the analysis and findings for each concern, and • A statement to the practitioner informing him/her that their consent is not required for the QIO to disclose specific findings about the review to the beneficiary. This information should be consistent with the information contained in the QRD Form (See §5230.2)]. Please direct your response to: [Insert QIO Name] [Insert QIO Contact Person] [Insert QIO Address] [Insert QIO Contact Number] [Insert QIO Fax Number] If you have any questions about this letter or would like to make arrangements to discuss this case, contact the person listed above. If the concerns involve both a physician/practitioner and a provider, the physician/practitioner and the representative for the provider may respond separately to the opportunity for discussion. However, we strongly encourage coordination of the responses. If we do not receive your response within 7 calendar days from the receipt of this letter, the Initial Determination will become our Final Determination, and we will send you a letter noting this change. The information in this letter is confidential, and you may disclose it only in accordance with Federal regulations found in 42 CFR Part 480. If you have any questions about this letter, please contact the above-named person within the time frame described above. Sincerely, Medical Director (or designated physician) [Insert title here] Appendix 5-4 – Final Initial Determination Letter to Practitioners/Providers with Request to Disclose (For Beneficiary Complaints) (Rev. 17, Issued: -04-06-12, Effective: 05-07-12 Implementation: 05-07-12) QIO LETTERHEAD Date of Notice Name of Addressee Address City, State, and Zip Code Patient Name (when the patient has consented to disclosure) Health Insurance Claim (HIC) Number Practitioner/Provider Name (If this applies) Practitioner/Provider Number (If this applies) Date of Admission/Service Medical Record Number (if known) Dear: Previously, you were afforded the opportunity to discuss our review of care you provided in our letter (dated _____). This letter constitutes our Final Initial Determination based on a careful review of the information provided by the beneficiary in filing the complaint, information contained in the medical information, as well as any information provided during the opportunity for discussion. Summary of Findings The results of our review are as follows: PREPARATION NOTE FOR QIO The summary must include: • the specific concerns identified by the beneficiary and any concerns identified by the QIO based on the Scope of Review (See §5110.1), • the standard of care associated with each concern, and • a statement of the analysis and findings regarding each concern, including specific information detailing the evaluation of information obtained as a result of the opportunity for discussion and any differences and/or changes between the Interim and Final Initial Determinations. The information should be consistent with the information contained in the Quality Review Decision (QRD) Form. Consent to Release Findings to the Beneficiary We will inform beneficiaries about whether the care they were provided did or did not meet professionally recognized standards of care. In order for us to release to the beneficiary more specific facts about the actions of particular practitioners involved in the care of the beneficiary, and how their actions did or did not meet the standard of care, we must obtain consent from those practitioner(s) The findings we propose releasing to the beneficiary are attached to (or included in) this letter. If you are a practitioner, please review the language and indicate consent to our disclosing the information to the beneficiary within thirty calendar days from the date of this letter. Please note that we will treat your failure to indicate your consent as your declining to consent and the beneficiary will not be informed of these specific findings. In order to facilitate release of these specific findings to the beneficiary, please contact the QIO representative named below to discuss the attached findings: Name of QIO Contact Person Address Telephone Number PREPARATION NOTE FOR QIO: • If the notice is addressed to the provider and/or physician practice or some other practitioner, insert the name of the practitioner(s) also notified and include the statement: o The following practitioner, [insert name(s)] also has been notified of our Final Initial Determination and contacted to obtain his/her consent to disclose the specific findings to the beneficiary. • If the notice is addressed to a practitioner, insert the name of the provider if applicable. Do not specify other physicians or practitioners you may be notifying. • If the notice is addressed to the provider and will also be sent to a physician practice or some other practitioner, insert into the provider’s notice the name(s) of the practitioner(s) also notified and include the statement: o The following practitioner(s), [insert name(s)] also has been notified of our Final Initial Determination and contacted to obtain his/her consent to disclose the specific findings to the beneficiary. • If the notice is addressed to a practitioner or physician practice, insert the name of the provider if applicable. Do not specify other physicians or practitioners you may be notifying. Right to Request a Re-Review PREPARATION NOTE FOR QIO The QIO must select the appropriate paragraph depending on whether a Retrospective or Concurrent Review is being conducted (Do NOT include “For Retrospective Review” or “For Concurrent Review” heading in the actual letter). In addition, the references to the other practitioners receiving the letter should not be included if addressed to a practitioner. For Retrospective Review We are also notifying (name (See NOTES above)) of our Final Initial Determination. If you or (name (See NOTES above)) disagree with this Final Initial Determination, either party may request a Re-Review. To request a Re- Review, you must submit your request in writing within 15 calendar days from the date of this letter. Your request for a Re-Review may include additional information and/or documentation, including medical information you believe supports your request for a Re-Review. For Concurrent Review We are also notifying (name (See NOTES above)) of our Final Initial Determination. If you or (name (See NOTES above)) disagree with this Final Initial Determination, you must submit your request in writing within 5 calendar days from the date of this letter. Your request for a Re-Review may include additional information and/or documentation, including medical information you believe supports your request for a Re-Review. Your request for a Re-Review may be submitted via mail or facsimile to the following address: QIO Name Address Facsimile Number Please be advised that if a Re-Review is requested, you [practitioner] will again be provided the opportunity to consent to our disclosing information to the beneficiary after the Re-Review determination. The information in this notice is confidential and may be re-disclosed only in accordance with federal regulations found in 42 CFR Part 480. Sincerely, Medical Director (or designated physician) (Include title) Appendix 5-4.1 – Beneficiary Quality of Care Complaint: Final Determination Letter to Practitioners and Providers (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) QIO LETTERHEAD Date of Notice QIO Liaison for Provider or Practitioner’s Name Name of Addressee Address City, State, and Zip Code Beneficiary Name Medicare # (HICN) Practitioner/Provider Name Practitioner/Provider Number (CCN/NPI/UPN) Date(s) of Service Dear [insert name of Practitioner or Provider here]: In our Initial Determination Letter, dated [insert date here], you were given the opportunity to discuss our review of the care you provided. This letter constitutes our Final Determination based on a review of the complaint, the medical information, and any correspondence provided during the opportunity for discussion. Summary of Review A QIO Peer Reviewer has reviewed the care provided to [Insert name of beneficiary relevant to the complaint] by [name of practitioner] or at [name of provider]. Based on an evaluation of the information received, the following is the summary of our review. Confirmed and/or identified concern(s) [should be the same as in the Interim Determination Letter] NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN THE LETTER PREPARATION NOTE FOR THE QIO The summary must include: • The specific concerns identified by the beneficiary and any concerns identified by the QIO based on the Scope of Review (See §5110.1), • The standard of care associated with each concern, • A statement of the analysis and facts the QIO determines are pertinent to its findings, including references to medical information and, if held, information obtained as a result of the opportunity for discussion with the involved practitioner or provider, and • For each concern, there should be a statement about whether or not the care provided was consistent with standards of health care. This information should be consistent with the information contained in the QRD Form (See §5230.2)] If [Insert QIO name here] identifies quality of care concerns that represent a significant departure from the expected standard of health care and/or identifies patterns of care that may have significance beyond a single episode, a determination may be made that further intervention activities are required. If this occurs, you will be notified in writing and given the opportunity to discuss the concern(s) with [Insert QIO name here]. Non-confirmed concern(s): NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN THE LETTER. PREPARATION NOTE FOR QIO The summary must include: • The specific concerns identified by the beneficiary and any concerns identified by the QIO based on the initial intake (See §5110.1). • The standard of care associated with each concern and a statement of the analysis and facts the QIO determines are pertinent to its findings, including references to medical information and, if held, information obtained as a result of the opportunity for discussion with the involved practitioner or provider. This information should be consistent with the information contained in the QRD Form (See §5230.2)] This information will be entered into [the CMS database]. On an ongoing basis, we analyze patterns of care involving quality concerns that may have significance beyond a single episode. The QIO provides this information to CMS as requested. Please be advised that the Medicare Beneficiary has the right to request Reconsideration. If a request is received, this determination may or may not change as a result of the QIO reviewing this case again during the Reconsideration process. In the event that the Reconsideration does result in a change in the Final Determination, you will be notified in writing.] Right to Request Reconsideration If you disagree with this Final Determination, you may also request Reconsideration by submitting your request within 3 calendar days from the receipt of this letter. Your request for Reconsideration may include additional information and/or documentation, including Your request for Reconsideration can be either written or oral using the contact information below: [Insert QIO Name] [Insert QIO Contact Person] [Insert QIO Address] [Insert QIO Contact Number] [Insert QIO Fax Number] Please be advised that if Reconsideration is requested, this determination may or may not change as a result of the QIO reviewing this case again during the Reconsideration process. In the event that the Reconsideration does result in a change in the Final Determination, you will be notified in writing. The information in this notice is confidential and may be disclosed only in accordance with Federal regulations found in 42 CFR Part 480. Sincerely, Medical Director (or designated physician) [Insert title here] Appendix 5-4.2 – Beneficiary Quality of Care Complaint: Final Determination Letter to Beneficiary/ Beneficiary Representative (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) QIO LETTERHEAD Date of Notice Name of Addressee Address City, State, and Zip Code Beneficiary Name Medicare # (HICN) Practitioner/Provider Name Practitioner/Provider Number (CCN/NPI/UPN) Date(s) of Service Dear [insert name of Beneficiary or Representative] Thank you for your patience while we completed a full and comprehensive review of the quality of care concerns you raised [(If available, include copy of the quality of care concern form signed by the complainant]). Our Final Determination is based on a physician’s careful review of: • Information you provided in filing the complaint • Medical information • Any information provided during the practitioner/provider’s opportunity for discussion. Summary of Review The following is the summary of our review. Confirmed and/or identified concern(s): NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN THE LETTER. PREPARATION NOTE FOR THE QIO The summary must include: • The specific concerns identified by the beneficiary and any concerns identified by the QIO based on the initial review (See §5110.1), • The standard of care associated with each concern, and • A summary of the analysis and facts the QIO determines are pertinent to its findings, including references to medical information and, if held, information obtained as a result of the opportunity for discussion with the involved practitioner or provider. The information should be consistent with the information contained in the QRD Form (See §5230.2)] Non-confirmed concern(s): NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN LETTER PREPARATION NOTE FOR THE QIO The summary must include: • The specific concerns identified by the beneficiary and any concerns identified by the QIO based on the Scope of Review (See §5110.1), • The standard of care associated with each concern, and • A summary of the analysis and facts the QIO determines are pertinent to its findings, including references to medical information, and including any information obtained as a result of the opportunity for discussion with the involved practitioner or provider. The information should be consistent with the information contained in the QRD Form (See §5230.2]. Your Right to Request a Reconsideration If you disagree with this determination, you may request Reconsideration by submitting your request within three (3) calendar days from the receipt of this letter. You may provide additional information and/or documentation, including medical information that will help with your request. Your request for Reconsideration can be either written or oral using the contact information below: [Insert QIO Name] [Insert QIO Contact Person] [Insert QIO Address] [Insert QIO Contact Number] [Insert QIO Fax Number] NOTE: The determination in this letter may or may not change as a result of us reviewing this case again during the Reconsideration process. If it does, you will be notified in writing. The information in this notice is confidential and may be disclosed only in accordance with Federal regulations found in 42 CFR Part 480. Sincerely, Medical Director (or designated physician) [Insert title here] Appendix 5-5 – Re-Review Determination Letter to Providers/Practitioners with Request to Disclose (For Beneficiary Complaints) (Rev. 17, Issued: -04-06-12, Effective: 05-07-12 Implementation: 05-07-12) QIO LETTERHEAD Date of Notice Name of Addressee Address City, State, and Zip Code Patient Name (when the patient has consented to disclosure) Health Insurance Claim (HIC) Number Practitioner/Provider Name (if this applies) Practitioner/Provider Number (if this applies) Date of Admission/Service Medical Record Number (if known) Dear: Previously, you received our Final Initial Determination letter, dated _________, about care you provided [to the beneficiary listed above. (Only include where the beneficiary has consented to the disclosure of his or her name.)] We received your request for a Re- Review, and have completed the Re-review. This letter conveys the final results of our Re-Review and constitutes our FINAL decision on this matter. The Re-review was completed by a Peer Reviewer who was not involved in the original Determination. Summary of Re-Review Findings Based on a thorough review of all information, the Re-Review Peer Reviewer has determined PREPARATION NOTE FOR QIO The summary must include: • the specific concerns identified by the beneficiary and any concerns identified by the QIO based on the Scope of Review (See §5110.1), • the standard of care associated with each concern, and • a statement of the analysis and findings regarding each concern, including the analysis of any additional information submitted as part of the Re- Review request and/or changes between the Initial Determination and Re- Review. This information should be consistent with the information contained in the Quality Review Decision (QRD) Form. Consent to Release Findings to the Beneficiary We will inform beneficiaries about whether the care they were provided did or did not meet professionally recognized standards of care. In order for us to release more specific findings to the beneficiary, we must obtain consent from practitioner(s) involved in the care of the patient. The findings we propose releasing to the beneficiary are attached to (or included in) this letter. If you are a practitioner, please review the language and indicate consent to our disclosing the information within thirty calendar days from the date of this letter. Please note that we will treat your failure to indicate your consent as your declining to consent, and the beneficiary will not be informed of these specific findings. In order to facilitate release of these specific findings to the beneficiary, please contact the QIO representative named below to discuss the attached findings: Name of QIO Contact Person Address Telephone Number PREPARATION NOTE FOR QIO: • If the notice is addressed to the provider or practitioner group, insert the name of the practitioner(s) also notified and the following language. • The following practitioner, [insert name(s)] also has been notified of our Re-Review decision and contacted to obtain his/her consent to disclose the specific findings to the beneficiary. • If the notice is addressed to the practitioner, insert the name of the provider if applicable. Do not specify other practitioners you may be notifying. • If the notice is addressed to the provider and will also be sent to a physician practice or some other practitioner, insert into the provider’s notice the name(s) of the practitioner(s) also notified and include the statement: o The following practitioner(s), [insert name(s)] also has been notified of our Final Initial Determination and contacted to obtain his/her consent to disclose the specific findings to the beneficiary. • If the notice is addressed to a practitioner or physician practice, insert the name of the provider if applicable. Do not specify other physicians or practitioners you may be notifying. Again, this constitutes the QIO’s FINAL decision on this matter, and no further appeal rights are available. The information in this notice is confidential and may be re- disclosed only in accordance with Federal regulations found in 42 CFR Part 480. Sincerely, Medical Director (or designated physician) (Include title) Appendix 5-5.1 – Beneficiary Quality of Care Complaint: Reconsideration Determination Letter to Practitioners and Providers (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) QIO LETTERHEAD FINAL NOTIFICATION Date of Notice QIO Liaison for Provider’s or Practitioner’s Name Name of Addressee Address City, State, and Zip Code Beneficiary Name Medicare # (HICN) Practitioner/Provider Name Practitioner/Provider Number (CCN/NPI/UPN) Date(s) of Service [NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN THE LETTER. • If the notice is addressed to the provider or practitioner group, insert the name of the practitioner(s) also notified. • If the notice is addressed to the practitioner, insert the name of the provider if applicable. Do not specify other practitioners you may be notifying. • If the notice is addressed to the provider and will also be sent to a physician practice or some other practitioner, insert into the provider’s notice the name(s) of the practitioner(s) also notified. • If the notice is addressed to a practitioner or physician practice, insert the name of the provider if applicable. Do not specify other physicians or practitioners you may be notifying.] Dear [Insert name of Practitioner or Provider here]: You previously received our letter, dated [insert date here], about care you provided to [insert beneficiary name here]. We received your request for Reconsideration and have completed the Peer Review. Following CMS policy, a Peer Reviewer who was not involved in the prior determination of the initial review completed the Reconsideration review. This letter conveys the results of your Reconsideration review and constitutes our final decision on this matter. Summary of Reconsideration Review Based on a review of the information received, the following is the summary of our Reconsideration review. Confirmed and/or identified concern(s) [should be the same as Final Determination letter]: [NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN THE LETTER. PREPARATION NOTE FOR THE QIO The summary of confirmed concerns must include: • The specific concerns identified by the beneficiary and any concerns identified by the QIO based on the Scope of Review (See §5110.1), • The standard of care associated with each concern, and • A summary of the analysis and facts the QIO determines are pertinent to its findings, including references to medical information and, if held, information obtained as a result of the opportunity for discussion with the involved practitioner or provider. The information should be consistent with the information contained in the QRD Form (See §5230.2]. Non-confirmed concern(s): NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN LETTER PREPARATION NOTE FOR THE QIO The summary must include: • The specific concerns identified by the beneficiary and any concerns identified by the QIO based on the Scope of Review (See §5110.1), • The standard of care associated with each concern, and • A summary of the analysis and facts the QIO determines are pertinent to its findings, including references to medical information and, if held, information obtained as a result of the opportunity for discussion with the involved practitioner or provider. The information should be consistent with the information contained in the QRD Form (See §5230.2)] This information will be entered into [the CMS database]. On an ongoing basis, we analyze patterns of care involving quality concerns that may have significance beyond a single episode. The QIO provides this information to CMS upon request. Again, this constitutes the QIO’s final decision on this matter, and no further appeal rights are available. The beneficiary or patient representative will be notified of the results of the QIO Quality of Care Review. The information in this notice is confidential and may be disclosed only in accordance with Federal regulations found in 42 CFR Part 480. Sincerely, Medical Director (or designated physician) [Insert title here] Appendix 5-5.2 – Beneficiary Quality of Care Complaint: Reconsideration Determination Letter to Beneficiary/Beneficiary Representative (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) NOTE: This letter template applies to beneficiary complaints received after July 31, 2014. QIO LETTERHEAD Date of Notice Name of Addressee Address City, State, and Zip Code Beneficiary Name Medicare # (HICN) Practitioner/Provider Name Practitioner/Provider Number (CCN/NPI/UPN) Date(s) of Service Dear [insert name of Beneficiary or Representative here] We received your request for a different reviewer to look at your quality of care concerns under the Reconsideration process. The Reconsideration review findings are below, and this is our final determination about the quality of the medical care you received. Summary of Review The following is the summary of our Reconsideration Peer Review. Confirmed and/or identified concern(s) [should be the same as Final Determination letter]: [NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN THE LETTER. PREPARATION NOTE FOR THE QIO The summary must include: • The specific concerns identified by the beneficiary and any concerns identified by the QIO based on the Scope of Review (See §5110.1), • The standard of care associated with each concern, and • A summary of the analysis and facts the QIO determines are pertinent to its findings, including references to medical information and, if held, information obtained as a result of the opportunity for discussion with the involved practitioner or provider. The information should be consistent with the information contained in the QRD Form (See §5230.2)] Non-confirmed concerns: NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN LETTER PREPARATION NOTE FOR THE QIO The summary must include: • The specific concerns identified by the beneficiary and any concerns identified by the QIO based on the Scope of Review (See §5110.1), • The standard of care associated with each concern, and • A summary of the analysis and facts the QIO determines are pertinent to its findings, including references to medical information and, if held, information obtained as a result of the opportunity for discussion with the involved practitioner or provider. The information should be consistent with the information contained in the QRD Form (See §5230.2)] This information will be entered into [the Centers for Medicare & Medicaid Services (CMS) database]. On an ongoing basis, we review quality of care services and concerns that may identify patterns of care that may have significance beyond a single episode. The QIO provides this information to CMS as requested to improve the overall quality of care for all Medicare beneficiaries. Again, this is the final decision on this matter, and no further appeal rights are available. In addition, the information in this notice is confidential and may be disclosed only in accordance with Federal regulations found in 42 CFR Part 480. Thank you for sharing your concerns with us. If you have any questions, please do not hesitate to contact us: [Insert QIO Name] [Insert QIO Contact Person] [Insert QIO Address] [Insert QIO Contact Number] [Insert QIO Fax Number] Sincerely, Medical Director (or designated physician) [Insert title here] Appendix 5-6 – General Quality of Care Reviews - Initial Determination Letter with Right to Request Reconsideration to Practitioners and Providers (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) QIO LETTERHEAD INITIAL NOTIFICATION Date of Notice QIO Liaison for Provider or Practitioner’s Name Name of Addressee Address City, State, and Zip Code Beneficiary Name Medicare # (HICN) Practitioner/Provider Name Practitioner/Provider Number (CCN/NPI/UPN) Date(s) of Service Dear [Insert name of Practitioner or Provider here]: You are receiving this notification because [Insert QIO name here] identified a potential quality of care concern about care you provided to [Insert beneficiary name here]. [Insert QIO name here] is the Quality Improvement Organization (QIO) authorized by the Centers for Medicare & Medicaid Services (CMS) to review Medicare cases in [Insert QIO area/region here] to determine if the health care services provided to Medicare beneficiaries meet professionally recognized standards of care, are medically necessary, and are delivered in the most appropriate setting. Our primary purpose is to identify areas where health care services can be improved and provide feedback to facilities and practitioners. This Peer Review is intended to be a collegial interaction with the goal of improving patient care. We have completed our review of the episode of care referenced above. A [Insert QIO name here] Peer Reviewer has carefully reviewed the medical information. Summary of Review Based on a review of the information received, the following is the summary of our review. Confirmed and/or identified concern(s): [NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN THE LETTER PREPARATION NOTE FOR THE QIO: The review findings must include: • A statement for each quality of care concern that care did or did not meet the standard(s) of care, • The standard(s) identified by the QIO for each quality of care concerns, and • A specific statement conveying facts describing how the practitioner and/or provider did or did not meet specific criteria within the standard. Non-confirmed concern(s): NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN LETTER PREPARATION NOTE FOR QIO: The review findings must include: • A statement for each of the quality of care concerns that care did or did not meet the standard(s) of care, • The standard(s) identified by the QIO for each quality of care concerns, and • A statement for each quality of care concern that care did or did not meet the standard(s) of care. If you disagree with this quality of care concern(s) determination, you may request Reconsideration. Your request should include the reason for your dissatisfaction with our determination and any additional information you may wish to submit. Your request for Reconsideration can be written or oral and must be submitted within three (3) calendar days from receipt of this letter using the following contact information: [Insert QIO Name] [Insert QIO Contact Person] [Insert QIO Address] [Insert QIO Contact Number] [Insert QIO Fax Number] NOTE: If a request for Reconsideration is not submitted within the appropriate timeframe, this notification will be considered our Final Determination. This information will be entered into [the Centers for Medicare & Medicaid Services (CMS) database]. On an ongoing basis, we analyze patterns of care involving quality concerns that may have significance beyond a single episode. The QIO provides this information to CMS as requested to improve the overall quality of care for all Medicare beneficiaries. The information in this notice is confidential and may be disclosed only in accordance with Federal regulations found in 42 CFR Part 480. Thank you for your participation in the improvement of the Medicare program. Sincerely, Medical Director (or designated physician) [Insert title here] Appendix 5-7 – General Quality of Care Reviews: Final Reconsideration Determination Letter to Practitioners and Providers (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) NOTE: Use this letter template if a request for reconsideration is submitted within the appropriate timeframe. QIO LETTERHEAD FINAL NOTIFICATION Date of Notice QIO Liaison for Provider or Practitioner’s Name Name of Addressee Address City, State, and Zip Code Beneficiary Name Medicare # (HICN) Practitioner/Provider Name Practitioner/Provider Number (CCN/NPI/UPN) Date(s) of Service Dear [insert name of Practitioner or Provider here]: You previously received our Initial Determination letter, dated [Insert date here], about the care you provided to [Insert beneficiary name here]. We received your request for Reconsideration, and have completed the Reconsideration Peer Review. A [Insert QIO name here] Peer Reviewer has carefully reviewed the medical information, and any additional information that was provided. This Peer Reviewer was not the same Peer Reviewer who initially reviewed this matter. This letter conveys the results of your Reconsideration and constitutes our final decision on this matter. Summary of Review Based on a review of the information received, the following is the summary of our review. Confirmed and/or identified concern(s): NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN THE LETTER PREPARATION NOTE FOR THE QIO: The review findings must include: • A statement for each quality of care concern that care did or did not meet the standard(s) of care, • The standard(s) identified by the QIO for each quality of care concern, and • A specific summary conveying facts describing how the practitioner and/or provider did or did not meet specific criteria within the standard. Non-confirmed concern(s): NOTE: The following is for instructional purposes ONLY. DO NOT INCLUDE IN LETTER PREPARATION NOTE FOR QIO: The review findings must include: • A statement for each quality of care concern that care did or did not meet the standard(s) of care, • The standard(s) identified by the QIO for each quality of care concern, and • A specific summary conveying facts describing how the practitioner and/or provider did or did not meet specific criteria within the standard.] This information will be entered into [the Centers for Medicare & Medicaid Services (CMS) database]. On an ongoing basis, we analyze patterns of care involving quality concerns that may have significance beyond a single episode. The QIO provides this information to CMS as requested. The information in this notice is confidential and may be disclosed only in accordance with Federal regulations found in 42 CFR Part 480. Thank you for your participation in the improvement of the Medicare program. Sincerely, Medical Director (or designated physician) [Insert title here] Appendix 5-8 – REQUEST FOR QIO REVIEW FORM (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) TO: QIO Name Address City, State, Zip I. Requesting Agency/Organization and Contact Person Agency/Organization: Phone #: Contact Person: Email: II. Patient Information Patient Name: HIC #: Date of Birth: Sex: Male __ Female Facility Name: Provider Name: Provider Phone #: Admit Date: Discharge Date: III. Referral Type of Referral (check one): Quality of Care: Other: Reason for Review Request or Quality of Care Concern Identified (be specific): (Quality of Care e.g., over-prescribing drugs or prescribing the wrong drug, failing to diagnose a medical problem that is found later, misreading x-rays to identify a medical problem, failing to get back to a patient with medical results in a timely manner, failing to provide appropriate care after a surgical procedure) Reviewer’s Signature Date Do you need an update on case upon completion of QIO’s review? (Check one): Yes No THIS SECTION FOR QIO USE ONLY Was a review conducted? Yes No Review Results: Additional Information: Appendix 5-9 – Best Practices (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Beneficiary Complaint Review Review Type Timing Reference Intake Stage QIO during initial intake of information from the beneficiary will accept the complaint when received in writing The date of service on which the care that gave rise to the complaint occurred is less than three (3) years from the date of the phone call to the QIO. If service was more than 3 years before the date of the call or complaint to the QIO, the QIO cannot review the matter under 42 CFR 476.120(a). 5045.2 QIO intakes initial information from the beneficiary One (1) business day of initial contact 5030.2 QIO responds to messages received after hours Next business day 5030.2 QIO mails Complaint form One (1) business day of Intake 5040 Failure to return form, QIO contacts beneficiary Fifteen (15) calendar days from mailing 5040.2 Failure to return form, the QIO has insufficient information to proceed with a review and closes complaint. Review processed as Quality of Care Review if serious or urgent concern present. Thirty-one (31) calendar days from mailing 5040.2 QIO uploads form into CMS-designated case review system for Review Analyst review One (1) business day of receipt 5040.3 Review Analyst contacts beneficiary, orally acknowledges receipt of complaint One (1) business day of receipt 5040.3 Immediate Advocacy Review Type Timing Reference Look back period for Immediate Advocacy Six (6) months from the date of service which care occurred involving the complaint 5035.2 Time frame for QIO to make a final decision for an Immediate Advocacy Eight (8) hours to two (2) days is average, but no more than ten calendar days from the time the Immediate Advocacy began 5035.4 Review Analyst updates CMS-designated system about result of Immediate Advocacy One (1) business day after Immediate Advocacy is completed 5035.5 Requesting Medical Information Medical information requested One (1) business day from receipt of written complaint 5045.2 Due date of all medical information Fourteen (14) calendar days from date of request or sooner if complaint involves a gross and flagrant of substantial quality of care issue. 5045.2 Medical information not received by deadline calendar day 14 or earlier if concern was potentially gross and flagrant or a substantial quality of care issue and QIO determines that circumstances warrant earlier receipt of information. Contact the COR immediately who contacts provider by the next business day 5045.2 Medical information not received by calendar day 30 Contact COR and notify the Beneficiary on the next business day 5045.3 Medical information received Immediately date-stamp and upload into CMS-designated case review system within one business day 5045.4 Information missing/ illegible in medical information Contact provider/practitioner and provide five (5) calendar days to submit corrections 5045.4 Quality of Care Review Stage Review Type Timing Reference Review Analyst completes Quality Review Decision (QRD) Form and forwards package to Initial Determination Peer Reviewer(s) (IDPR) Within a reasonable amount of time to ensure the ten calendar day timeframe is met 5050.2 IDPR completes review and returns package to Review Analyst and reviews IDPR decision Within the 10 calendar day timeframe from receipt of the medical record 5050.2 Opportunity for Discussion Stage Review Analyst offers opportunity for discussion One (1) business day after reviewing the IDPR determination 5055.1 Response to opportunity for discussion Seven (7) calendar days from initial offer 5055.1 Extension of response time for opportunity for discussion Additional seven (7) calendar days in rare circumstances 5055.1 Review Analyst forwards to IDPR information received during opportunity for discussion One (1) business day from receipt of oral/written response 5055.4 IDPR considers information received and makes Final Determination Three (3) business days 5055.4 No response to offer of opportunity for discussion Seven (7) calendar days, then Interim Initial Determination becomes Final Determination 5055.6 Review Analyst forwards Final Initial Determination Letter Three (3) business days of receipt of all of the QRD Form or one business day of expiration of opportunity for discussion if no response received 5055.6 Practitioner/provider requests a Reconsideration Three (3) calendar days from receipt of the Final Determination Letter 5060 IDPR destroys copies of all materials Thirty (30) calendar days 5055.8 Beneficiary Complaint Reconsideration Procedure Review Type Timing Reference Beneficiary must inform QIO of his/her request for a Reconsideration in writing or by phone No later than three (3) calendar days following the initial notification of the QIO’s determination 5060 Review Analyst forwards Beneficiary Complaint folder to Reconsideration Peer Reviewer Within one (1) business day of receipt of request 5060 RPR completes the Reconsideration review, returns folder, and the beneficiary and provider are notified of the decision. Within five (5) calendar days after receiving any medical or other records needed for reconsideration 5060.1 Review Analyst mails Final Decision to beneficiary Within five (5) calendar days of request or if later within 5 calendar days of receipt of medical information 5060.4 Appendix 5-10 – General Quality of Care - Best Practices (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) General Quality of Care Review Review Type Timing Reference Intake Stage QIO intake person forwards folder to Review Analyst One (1) business day of receipt of referral/identification of concern 5110 Requesting Medical Information Medical information requested One (1) business day from receipt/identification of concern 5110.2 Due date of medical information Fourteen (14) calendar days from date of request or sooner if complaint involves a gross and flagrant of substantial quality of care issue. 5110.2 Medical information not received by deadline calendar day 14 or earlier if concern was potentially gross and flagrant or a substantial quality of care issue and QIO determines that circumstances warrant earlier production of medical records) Contact COR immediately 5110.2 Medical information not received by the next business day following deadline COR calls practitioner/provider the next business day 5110.2 Medical information not received from provider, then initiate claim denial 15 calendar days from date of request or sooner if complaint involves a gross and flagrant of substantial quality of care issue. 5110.2 QIO receives medical information Immediately date-stamp and upload into CMS-designated case review system within one business day 5110.4 Information missing/illegible in medical information QIO contacts provider/practitioner and provides five (5) calendar days to submit corrections 5110.4 Quality of Care Review Stage Review Type Timing Reference Review Analyst completes QRD Form and forwards package to Initial Determination Peer Reviewer (IDPR) Within a reasonable amount of time to ensure the 10-calendar- day time frame is met 5115.1 IDPR completes review, returns package to the Review Analyst, and notifies practitioner/provider of Initial Determination Decision Ten (10) calendar days from receipt of package, including all medical information 5115.2 IDPR destroys copies of all materials Thirty (30) calendar days after Final Initial Determination 5115.5 Reconsideration Stage Practitioner/provider must file a written or oral request for a Reconsideration Three (3) calendar days following the receipt of the QIO Initial Determination 5115.5 Review Analyst forwards Beneficiary Complaint folder to the Reconsideration Peer Reviewer Within one (1) business day of receipt of request 5115.5 Review Analyst prepares and mails Final Decision Letter Within five (5) calendar days after receipt of request for a reconsideration, or 5 calendar days after receiving all medical information 5120.1