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QIO TRANSMITTAL SERIES ISSUE: Utilization Review Process - Printable
pages The Foundation’s Case Review Specialists
use various criteria sets to screen cases to identify potential utilization
issues. Cases which fail to meet the
criteria are referred for review by a Physician Consultant. Further information on the use of the
criteria is provided in the transmittal entitled “Criteria”. Notices of Potential Denial of
Medicare Benefits When a QIO Physician Consultant initially
determines that an admission or days of stay are medically unnecessary, the
Foundation will issue a notice of potential denial of Medicare benefits. To the extent possible, the QIO Physician
Consultant will be of the same specialty as the attending physician. This notice will be sent to the attending
physician and the hospital review contact person and will provide the
opportunity to review the case and submit written comments. To be considered, any written comments
must be received within 20 days from the date of the Foundation's
notice. (The notice of potential
denial will specify the response date.)
As this timeframe has been established by CMS, the Foundation will not
be able to authorize any extensions for the submission of initial comments. The Foundation will issue the notices of
potential denial to the hospital and physician(s) who, according to the
medical record, was responsible for the patient at the point in time for
which services are being considered for denial. If no additional information is received
by the response date, the Foundation will issue a notice of denial of
Medicare benefits for these services.
Information received after the response date will not be able to
affect the initial determination; any information received after the response
date will be considered and handled as request(s) to initiate the
reconsideration process. The physician(s) and/or a physician
hospital representative may discuss the case with a QIO Physician
Consultant. If such discussion is
desired, it must be indicated in the written response. The Foundation will make arrangements for
the QIO Physician Consultant to contact the physician(s) requesting
discussion. A nonphysician hospital representative
may discuss the case with a Foundation staff member. If such discussion is desired, it must be
indicated in the written response.
The Foundation will then contact the hospital party requesting
discussion during routine business hours. All oral discussions and written
responses must be able to be substantiated by the patient's hospital medical
record for the admission under review. If any additional information is
received by the response due date, the Foundation will refer the case to a
QIO Physician Consultant. This QIO
Physician Consultant may be the same physician as the initial physician
reviewer. If the QIO Physician Consultant
determines, after reviewing the case with the additional information
provided, that the services which were being considered for denial are
medically necessary, the Foundation will issue a notice to this effect. If the QIO Physician Consultant
determines, after reviewing the case with the additional information
provided, that the services which were being considered for denial should not
be covered by Medicare, a notice to this effect, outlining further appeal
rights, will be issued. Reinstatement of Medicare Benefits The Foundation reviews all hospital
notices of noncoverage where there is patient liability. If a QIO Physician Consultant determines
that at the time of the hospital's notice the patient was at a covered level
of care under the Medicare program, the Foundation will issue a potential
notice of Reinstatement of Medicare Benefits to the attending physician and
the hospital review contact person.
The notice is issued to provide the attending physician and the
hospital with the opportunity to submit written comments. The review and response process is the
same as that described above for denials. If the QIO Physician Consultant
determines, after reviewing the case with the additional information
provided, that the proposed period(s) of reinstatement should be reinstated
(covered by Medicare), no further appeal rights are available as decisions
reinstating benefits/Medicare coverage are considered "positive"
determinations and are not subject to the appeal provisions for adverse
determinations. A notice with the
determination will be issued. If the QIO Physician Consultant
determines, after reviewing the case with the additional information
provided, that the proposed period(s) of reinstatement should not be
reinstated (not covered by Medicare) a notice to this effect, outlining
further appeal rights, will be issued. November
2002 Next
Chapter: Criteria |
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Copyright © 2005 Northeast Health Care Quality Foundation, all rights
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