Form Cms-384 - Qio Case Summary

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

QIO CASE SUMMARY

1. MEDICARE NUMBER

2. BENEFICIARY

3. NAME OF QIO

TELEPHONE NUMBER

4. APPELLANT

5. DATE OF INITIAL DETERMINATION

6. DATE OF RECONSIDERATION DETERMINATION

7. DATE OF HEARING REQUEST

______/______/______

______/______/______

______/______/______

8. PROVIDER NAME AND TYPE

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HOSPITAL

SNF

HHA

OTHER

PROVIDER NUMBER

ADDRESS

CITY

STATE

ZIP

9. ISSUE

10. AMOUNT IN CONTROVERSY

11. DATE FORWARDED TO OHA

______/______/______

12. ADMISSION DATE

13. DAYS OR VISITS AT ISSUE

14. NUMBER

15. DATE

______/______/______

______/______/______

16. INTERMEDIARY NAME

ADDRESS

CITY

STATE

ZIP

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17. CURRENT STATUS

STILL PATIENT

DISCHARGED

DIED

18. PERTINENT EVIDENCE AND DATES

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HOSPITAL ADMISSION RECORD

PHYSICIAN ATTESTATION

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HOSPITAL DISCHARGE SUMMARY

ELIGIBILITY FORM

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NURSES NOTES

BILLING FORM

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MEDICATION CHARTS

CREDENTIALS OF PHYSICIAN RECONSIDERATION REVIEWER

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DOCTORS ORDERS

RATIONALE FOR DETERMINATION WITH CORRESPONDING STATUTE/REGULATION

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DOCTORS PROGRESS NOTES

COPIES OF PRIOR DENIAL/RECONSIDERATION NOTICES (for waiver of liability)

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PHYSICAL THERAPY NOTES

COPIES OF CRITERIA/MANUAL PAGES SUPPORTING DECISION, IF NECESSARY

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HOSPITAL TO SNF TRANSFER FORM

OTHER (i.e., M.D. Letters, Consultant’s Reports, Lab Tests,Graphic Charts, Etc. - Please

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Specify)

HISTORY AND PHYSICAL

19. COMMENTS AND OTHER PERTINENT FACTS

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A. REPRESENTATIVE ........................................................................................................................................................................

YES

NO

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B. COMPLETED APPOINTMENT OR REPRESENTATIVE FORM....................................................................................................

YES

NO

Form CMS-384 (3-92)