Basic Elements for Quality Concern Notices - (Rev. 4, 07-18-03)

7220 - Basic Elements for Quality Concern Notices - (Rev. 4, 07-18-03) Your quality concern notices must be clear, informative, and non-threatening (e.g., do not quote at length from QIO regulations). In addition, all notices must contain the following basic elements: A. Heading The heading of the notice must include:  Your letterhead;  The date of the notice;  The name and address of the addressee; and  Case-identifying information. Specify the patient's name, patient's health insurance claim number, provider name, provider number, date of admission/service, and medical record number (if known). B. Body The body of the notice must contain:  A salutation;  A brief statement concerning your duties and functions under the Act;  A brief statement explaining the purpose of your quality review activities and acknowledging the importance of the provider's/physician's cooperation;  A brief summary of the background of the case. Specify the name of the patient, the name of the provider, the procedure, treatment, condition, and/or services involved, as appropriate; and  A confidentiality and re-disclosure statement. C. Signature The notice must be signed by the medical director or the QIO physician to whom the medical director has delegated this authority. Include a title with the signature.