Final Quality Concern Determination Notices - (Rev. 4, 07-18-03)

7240 - Final Quality Concern Determination Notices - (Rev. 4, 07-18-03) A. Confirmed Quality Concern Determination In addition to the basic elements listed in §7220, the body of these notices must contain the following elements:  A statement that a QIO physician reviewer has reviewed the medical record and any additional information provided during the opportunity for discussion;  A summary of the case findings and concerns, including a preferred course of action which would have improved care, from the Initial/Final Decision portion of the PRAF (Attaching a copy of the PRAF and referring to the attachment is not acceptable). Although you may reference the categories for classifying your concerns, do not use the numbering scheme (e.g., A.1, B.3, C.40, D.99) in your notice;  A brief statement of your action to be taken. Explain that the results of your review will be entered into your database for pattern analysis and used for related analysis activities. Explain that the physician and provider will have ample opportunity to discuss any patterns involving confirmed quality concerns;  For physician notices, a statement that the provider is also being notified of the confirmed quality concern. Specify the name of the provider. Do not specify the name of any other physician(s) you may be notifying;  For provider notices, a statement that the involved physician(s) is also being notified of the confirmed quality concern. Specify the name of the physician(s); and  A statement of re-review rights. Specify the method of request (in writing), the timeframe for the request (30 calendar days), and that the request should include the reason for disagreement with the determination and any additional information to be considered in making a re-review determination. Include the name of a QIO contact person, your address, and telephone number. B. Favorable Quality Review Determination In addition to the basic elements listed in §7220, the body of these notices must contain the following elements:  A statement that a QIO physician reviewer has reviewed the medical record and any additional information provided during the opportunity for discussion;  A summary of the case findings and concerns, including the basis for your favorable determination, from the Initial/Final Decision portion of the PRAF (Attaching a copy of the PRAF and referring to the attachment is not acceptable). Although you may reference the categories for classifying your concerns, do not use the numbering scheme (e.g., A.1, B.3, C.40, D.99) in your notice;  A brief statement of your action to be taken. Explain that the results of your review will be entered into your database for pattern analysis and used for related analysis activities;  For physician notices, a statement that the provider is also being notified of your final determination. Do not specify the name of any other physician(s) you may be notifying; and  For provider notices, a statement that the involved physician(s) is also being notified of your final determination. Specify the name of the physician(s).