Attachment H - Clinical Appeals Template.pdf
PDF 140 KB Posted
- Attached to
- MLRM External Clinical Review BPA
- Solicitation number
- 36C10X24R0038
About this file
The document provided is an Attachment H - Clinical Appeals Template. This template is used by the Department of Veterans Affairs (VA) to conduct clinical reviews and appeals. The template outlines the required information to be included in a clinical appeal report, such as the case ID, patient name, event dates, practitioner information, specific review questions, reviewer findings, references, and the reviewer's credentials and specialty. The reviewer is required to attest that they are board certified, meet clinical qualification requirements, and have no conflict of interest.
The related federal contract opportunity is for the MLRM External Clinical Review BPA, solicitation number 36C10X24R0038, issued by the VA Strategic Acquisition Center Frederick. The scope of the contract includes peer review for quality management, management review, medical advisory opinions, executive summaries, reports, and inter-rater reliability studies. The BPAs will have a period of performance of five years. Quotes are due by July 02, 2024, at 10:00 AM ET, and all questions must be submitted by June 11, 2024, at 10:00 AM ET.
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Text version
CASE ID
CLINICAL APPEAL REPORT
Case ID:
Patient Name:
Event date(s) to be reviewed:
Episode of Care:
Practitioner to be reviewed:
Credential:
Specialty:
SPECIFIC QUESTIONS FOR REVIEWER:
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SPECIAL INSTRUCTIONS:
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REVIEWER FINDINGS:
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REFERENCES, IF APPLICABLE:
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REVIEWER’S CREDENTIAL & SPECIALTY:
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All contract reviewers are required to provide an attestation that they are board certified, meet clinical qualification requirements, and have no conflict of interest, prior to being assigned to complete a VHA clinical review.
Attachment H: Clinical Appeals Template
| REVIEWER FINDINGS: |
| REFERENCES, IF APPLICABLE: |
| REVIEWER’S CREDENTIAL & SPECIALTY: |
| All contract reviewers are required to provide an attestation that they are board certified, meet clinical qualification requirements, and have no conflict of interest, prior to being assigned to complete a VHA clinical review. |
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