Medicare Enrollee Request for Quality Improvement

7055 - Medicare Enrollee Request for Quality Improvement Organization (QIO) Immediate Review - (Rev. 4, 07-18-03) A. Enrollee Request If the Medicare enrollee or his/her representative disagree with the NODMAR and the Medicare enrollee remains in the hospital, he/she may request (no later than noon of the first working day after the day the notice was received) an immediate review by you. This request for review may be made by telephone or in writing (See 42 CFR 422.622). NOTE: In cases involving a M+CO located outside the QIO review area, the request for immediate QIO review must be made to and reviewed by the QIO that has the agreement (under 42 CFR 476.78) with the hospital treating the enrollee, not the QIO with the agreement with the M+CO. This means regardless of whether the determination was made by a M+CO or a hospital, the QIO that has the agreement with the M+CO is not involved (see chapter 3, for the Memorandum of Agreement requirement related to NODMAR). B. M+C Notification On the day that you receive the enrollee's request for an immediate review, you must notify the M+CO. C. QIO Request for Medical Information The M+CO must take the following actions once an enrollee's request for an immediate review is confirmed:  The M+CO must supply any information that you require to conduct your review. This information must be made available to you, by telephone or in writing, by close of business of the first full working day immediately following the day the enrollee submits the request for review.  The M+CO must contact the hospital and request that the enrollee's medical records and other pertinent information be sent to you by close of business of the first full working day immediately following the organization's request. D. QIO Immediate Review  Solicitation of Views -- You must solicit the view of the enrollee or his/her representative that requested the immediate review (See §7020).  QIO Review Determination -- Once you have received all the necessary information from the hospital or the organization or both (e.g., medical records), review the case and notify the enrollee, the hospital, and the M+CO of your determination by close of business of the first working day following receipt of all pertinent information. Make your notification initially by telephone and follow up with a written notification (See §7015.B.1). E. Enrollee Liability Protection If the M+CO authorized coverage of the inpatient admission directly or by delegation (or the admission constitutes emergency or urgently needed services as described in 42 CFR 422.2 and 422.112(c)), the organization continues to be financially responsible for the costs of the hospital stay when a timely appeal is filed until noon of the calendar day following the day you notify the enrollee of your decision. NOTE: The hospital may not charge the M+CO (or the enrollee) if it was the hospital (acting on behalf of the enrollee) that filed the request for immediate QIO review and the QIO upholds the non-coverage determination made by the M+CO. F. Untimely Request for QIO Immediate Review If the request for an immediate review is not filed timely by the Medicare enrollee or his/her representative, do not review the case. Instructions found at 42 CFR 422.622(a)(2) provide an enrollee who fails to make a timely request for QIO review the fall-back option of requesting an expedited reconsideration from the M+CO. You must notify the beneficiary that his/her case is being referred to the M+CO for an expedited reconsideration (72 hour fast review). NOTE: The beneficiary is not entitled to subsequent review by the M+CO under the regulations at 42 CFR 422.582 and 42 CFR 422.584 once a QIO review is requested. Instead, the beneficiary has further appeal rights under 42 CFR 478. G. NODMAR Rescinded If the M+CO notifies you that the NODMAR has been rescinded after requesting the medical records, you should:  Instruct the hospital to submit the medical records (including a copy of the notice rescinding the NODMAR);  Review the medical record and determine whether or not the hospital acted appropriately in rescinding the notice;  Notify the beneficiary that the NODMAR was rescinded if you agree with the hospital’s action and that he/she should have received a written notification from the hospital; and  Issue your written initial determination (including a determination of the beneficiary’s liability for payment under §1869 of the Act) if you disagree with the hospital’s rescinded NODMAR. Because you do not monitor the issuance of the NODMAR, you are to refer to the Project Officer any single case where a NODMAR has been rescinded.