How will the QIC reconsideration process be different from the hearing officer function currently performed by FIs and Carriers?

September 20, 2009 by admin

The QIC's reconsideration will differ from a hearing officer hearing in many ways:

• Faster reconsideration timeframe. A QIC reconsideration must be completed within 60 days, as opposed to the 120-day timeframe for a hearing officer hearing.
• Panel of health professionals review. If the denial was based on medical necessity, the QIC must have a panel of physicians or other health care professionals with the appropriate clinical expertise to review your claim.
• Detailed information in your decision letter. The QIC must include a detailed explanation of the decision, including any pertinent facts and applicable regulations, and in the case of a medical necessity denial, an explanation of the medical and scientific reason for the decision.
• You may request "escalation." If the QIC doesn't issue its decision timely, you can chose to wait for the QIC's decision or escalate to the administrative law judge level of appeal.