Re-review of Quality Concerns - (Rev. 4, 07-18-03)

7310 - Re-review of Quality Concerns - (Rev. 4, 07-18-03) A. Applicability Although no reconsideration rights are available for final quality concern determinations, a physician or provider dissatisfied with your confirmed quality concern determination is entitled to a review of that determination. The physician or provider does not need to submit new information to be entitled to a re-review. This is an administrative appeal not required by statute or regulation. No additional review or appeal beyond this re-review is available for a confirmed quality concern determination. B. Request for a Re-review The physician or provider must file a written request for a re-review within 30 calendar days after the date of the receipt of a notice of a confirmed quality concern determination (Assume the date of receipt to be within 5 days of the date of the confirmed quality concern notice if absent proof to the contrary). In the case of late filing, determine whether the physician or provider has good cause for not requesting a re-review timely (see §7420.C).  Maintain a system for documenting your receipt of re-review requests. The receipt date, unless otherwise proven, is the date recorded in your documentation system. C. Qualifications of Physician Reviewers Who Render Quality Re-review Determinations Physician reviewers conducting re-reviews must meet the requirements for physician reviewers. Use a physician reviewer who was not involved in the determination of the confirmed quality concern to perform the re-review. D. Duties of Physician Reviewers Who Render Quality Re-review Determinations Duties of physician reviewers include:  Re-reviewing the original final determination about the quality concern, utilizing the medical record, the PRAF 1, the PRAF 2, and any additional information furnished by the physician or provider;  Making a final determination regarding the quality concern(s) and the source(s) of the quality concern(s); and  Completing the PRAF for re-review (PRAF 3). E. Timing of Re-review Complete your review and send a written notice within 30 calendar days after you receive the request for a re-review. F. Notices to Parties Issue a notice of a re-review determination for every case where a re-review is requested. Send the re-review notice to the provider and to the physician(s) affected by your re- review determination. G. Update of Data System (e.g., for pattern analysis, internal quality control) when notices of re-review determinations are sent out.