Re-review Quality Concern Notices - (Rev. 4, 07-18-03)

7250 - Re-review Quality Concern Notices - (Rev. 4, 07-18-03) A. Confirmed Quality Concern Upheld In addition to the basic elements listed in §7220, the body of these notices must contain the following elements:  The date of the re-review request;  An explanation that the physician reviewer who conducted the re-review was not involved in the original quality concern determination;  A statement that the QIO physician reviewer has re-examined the medical record and any additional information provided by the provider and/or physician;  A summary of the case findings and concerns, including a preferred course of action which would have improved care, from the Reconsideration/Re-review 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 the action to be taken. Explain that the results of your review will be entered into your database for pattern analysis, used for your related pattern analysis activities, and that the physician and provider will have ample opportunity to discuss any patterns involving quality concerns;  A statement that the re-review determination is final (i.e., no further appeals apply);  For physician notices, a statement that the provider is also being notified of your re-review determination. Specify the name of the provider. Do not specify the name of any other physician(s) you may be notifying; and  For provider notices, a statement that the affected physician(s) is also being notified of your re-review determination. Specify the name of the physician(s). B. Confirmed Quality Concern Reversed In addition to the basic elements listed in §7220, the body of these notices must contain the following elements:  The date of the re-review request;  An explanation that the physician reviewer who conducted the re-review was not involved in the original quality concern determination;  A statement that the QIO physician reviewer has re-examined the medical record and any additional information provided by the provider and/or physician;  A summary of the case findings and concerns, including the basis for your favorable determination, from the Reconsideration/Re-review 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 the action to be taken. Explain that the results of your review will be entered into your database for pattern analysis and your pattern analysis activities;  For physician notices, a statement that the provider is also being notified of your re-review determination. Specify the name of the provider. Do not specify the name of any other physician(s) you may be notifying; and  For provider notices, a statement that the affected physician(s) is also being notified of your re-review determination. Specify the name of the physician(s).