KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance. UM Retrospective Review Services.

Transcription

1 KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance UM Retrospective Review Services Provider Manual August 2017

2 This page intentionally blank

3 Table of Contents KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance TABLE OF CONTENTS Section 1: About Qualis Health... 1 Introduction... 1 Mission, Vision and Values... 1 Section 2: Communicating with Qualis Health... 2 Business Hours... 2 Contact Information... 2 Voice Mail... 2 Section 3: Compliance with URAC Utilization Review Standards Who makes utilization review decisions? Reconsideration process: What are the time frames for completion of non-urgent reviews?... 4 Section 4: HIPAA... 5 Business Associate Standing... 5 KDHE-DHCF Letter to Kansas Medicaid Providers... 5 Section 5: Web-based Utilization Review Submissions... 7 Qualis Health Provider Portal (QHPP)... 7 Purpose... 7 Responsibility... 8 Requirements... 8 Process and Procedures... 8 Section 6: Utilization Review Process Overview Case Selection Categories DRG Validation Review First-level Non-physician Review Second-level Peer Review Section 7: Retrospective Utilization Reviews Definition and Purpose Responsibility Process and Procedures Section 8: Potential Quality of Care Concerns i.

4 Table of Contents KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance Section 9: RECONSIDERATION AND ADMINISTRATIVE STATE FAIR HEARINGS 14 Reconsideration, Administrative Hearings, and Support Confidentiality of Medical Records Submission Appendix A: KMAP Hospital DRG Weights & Limits Link Appendix B: KDHE-DHCF and KMAP LINKS Appendix C: Key Contacts for Qualis Health Fax: (877) Appendix D: Process flow chart Appendix E: Letter 1 - adjusted DRG Appendix E: Letter 2 - Denial Appendix E: Letter 3 Denial OP Appendix E: Letter 4 Medical record Request Appendix E: Letter 5 - Medical record Request 1-OP Appendix E: Letter 6 - Medical record Request Appendix E: Letter 7 - Medical record Request 2-OP Appendix E: Letter 8 Reconsideration Modify Appendix E: Letter 9 Reconsideration Modify-OP Appendix E: Letter 10 Reconsideration Reverse Appendix E: Letter 11 Reconsideration Reverse OP Appendix E: Letter 12 Reconsideration UPHOLD Appendix E: Letter 13 Reconsideration UPHOLD-OP Appendix E: Letter 14 Request For Information Appendix E: Letter 15 Request For Information-OP Appendix E: Letter 16 Technical denial Appendix E: Letter 17 Technical denial-op i.

5 Section 1: About Qualis Health KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance SECTION 1: ABOUT QUALIS HEALTH Introduction Qualis Health has been designated by the Kansas Department of Health and Environment-Division of Health Care Finance (KDHE-DHCF) to safeguard against unnecessary utilization of care and services to assure the efficiency, economy and quality of care by providing Utilization Management Retrospective Review services for the State of Kansas. Qualis Health is a physician-sponsored organization. Our primary functions will include the operation of a review system to monitor the quality, diagnosis and procedure validation, medical necessity, discharge appropriateness, and appropriateness of health care provided. Qualis Health is a private, nonprofit healthcare QIO with 41 years of experience in providing utilization review, case management and quality improvement services. Qualis Health is one of the nation s leading healthcare consulting and care management organizations, helping to transform care and improve care delivery and patient outcomes. We work with clients throughout the public and private sectors to advance the quality, efficiency, and value of healthcare for millions of Americans every day. Programs offered include traditional utilization management services, such as preservice, concurrent, retrospective chart and telephonic review, coding validation, and medical consultation. Services designed for the managed care arena include the early identification of high-risk patients, specialty referral management services, consumer advocacy services, and audits of access to care Mission, Vision and Values Mission: To generate, apply and disseminate knowledge to improve the quality of healthcare delivery and health outcomes Vision: To be recognized for leadership, innovation and excellence in improving the health of individuals and populations Core Values: Integrity and professionalism, collaboration, and stewardship Issue Date: August 2017 Page 1

6 Section 2: Communicating with Qualis Health SECTION 2: COMMUNICATING WITH QUALIS HEALTH Business Hours Qualis Health s regular business hours are Monday through Friday 8 am to 5:00 pm Central Standard Time (CST), excluding holidays. Contact Information You may contact Qualis Health via the Qualis Health Provider Portal (QHPP) for information regarding specific case review and medical records that have been requested from Qualis Health; please see Section 6: WEB-BASED UTILIZATION REVIEW SUBMISSIONS You may also contact Qualis Health via telephone, fax, mail and (please do not send personal health information via ). QHPP UM Phone (877) UM Fax (877) Mail ksproviderportal@qualishealth.org Qualis Health PO Box 5268 Topeka, KS For detailed contact information, including staff addresses, see Appendix C, Key Contacts for Qualis Health and Kansas, or visit our website: Voice Mail Qualis Health s voice mail system is available 24 hours a day and you may leave a confidential voic . We will return messages left after regular business hours the next business day. Issue Date: August 2017 Page 2

7 Section 3: Compliance with Urac Utilization Review Standards KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance SECTION 3: COMPLIANCE WITH URAC UTILIZATION REVIEW STANDARDS Qualis Health complies with URAC health utilization management (UM) standards when performing utilization reviews. These standards provide a process for conducting a utilization review that is clinically sound and respects recipients and providers rights. URAC standards ensure that only appropriately trained, qualified clinical personnel conduct and oversee the utilization review process; that a reasonable and timely appeals process is in place; and that medical decisions are based on valid clinical criteria. Some frequently asked questions about the process of making utilization review decisions are answered next. Frequently Asked Questions About Utilization Review Decisions 1. Who makes utilization review decisions? URAC Health UM Accreditation requires Qualis Health to use a two-step process to determine if a proposed medical treatment or service is medically necessary: a. Initial Clinical Review: A licensed health professional, such as a registered nurse, licensed practical nurse, occupational therapist, physical therapist or social worker conducts this first critical step of the review process using InterQual medical necessity criteria and, as applicable, contract-specific criteria. If the clinical information provided does not meet InterQual criteria or, if in the clinical reviewer s judgment a physician should review the case, it is referred for second level peer review. b. Peer Clinical Review: A licensed physician qualified to render a clinical opinion about the proposed treatment or service performs a second level peer clinical review by evaluating all available information to determine whether or not care should be certified. 2. Reconsideration process: A provider may initiate a reconsideration request to Qualis Health when questioning a denial decision. The reconsideration is encouraged and will be performed by a qualified, board-certified physician peer consultant with the same or similar specialty as the attending physician and was not involved in the initial review decision. Issue Date: August 2017 Page 3

8 Section 3: Compliance with Urac Utilization Review Standards KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance 3. What are the time frames for completion of non-urgent reviews? When all necessary clinical information has been received the time frame for Qualis Health completion of reviews are as follows: Review Type Retrospective review Time Frame for Completion Thirty (30) calendar days When additional information is requested to complete the review, the timeline is adjusted accordingly to allow Qualis Health thirty (30) calendar days from receipt of all information necessary to complete the review. Issue Date: August 2017 Page 4

9 Section 4: HIPAA SECTION 4: HIPAA Business Associate Standing Qualis Health provides care management services on behalf of its clients and is considered a Business Associate of these clients under the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification regulations governing patient health information. These regulations include the Standards for Privacy of Individually Identifiable Health Information ( Privacy Rule ) and the Security Standard ( Security Rule ). KDHE-DHCF Letter to Kansas Medicaid Providers On June 22, 2017, KDHE-DHCF sent bulletin #17159 to providers regarding transition of the fee for service retrospective review program to Qualis Health. The bulletin is presented on the next page. Issue Date: August 2017 Page 5

10 Section 4: HIPAA KDHE-DHCF Letter to Kansas Medicaid Providers: Issue Date: August 2017 Page 6

11 Section 5: Web-based Utilization Review Submissions KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance SECTION 5: WEB-BASED UTILIZATION REVIEW SUBMISSIONS Qualis Health Provider Portal (QHPP) Qualis Health offers secure web-based review capability using the Qualis Health Provider Portal (QHPP) Zeomega s browser-based product that uses the Internet to create a two-way link that can be used to exchange care management data, thus facilitating real-time online approvals. Qualis Health also maintains dedicated toll-free phone and fax numbers for Medicaid providers who do not have Internet access to request review services. The QHPP offers feedback from Qualis Health regarding your retro review request. Reviews submitted via the QHPP receive notification of the final determination via the QHPP, and the state claim (ICN) number is posted on the QHPP. By using the QHPP, you do not need to wait for a phone call or a fax document to learn of the final determination. Providers must designate a Portal Administrator, who completes and submits a registration packet. Once Qualis Health receives the registration packet, we create a group account for the provider and assign a QHPP ID and password to the Portal Administrator. The Portal Administrator assigns individual IDs and passwords to provider staff members. Once trained, providers can log in to the QHPP and directly enter information for the admission (i.e. initial review, continued stay/concurrent review or retrospective review request). To get more information about the QHPP, or to learn how to submit web-based review requests, you can: QHPP materials for Kansas (e.g., registration packet, user guide, administrator guide, training materials): Information about training events (e.g., webinar dates and times): Download the QHPP User Guide: ksproviderportal@qualishealth.org If you do not have Internet access, fax Qualis Health s Kansas office at (877) for instructions on submitting your review. Purpose The QHPP allows physicians, facilities and other healthcare providers to attach documents, send and resend notes, receive alerts, and view determinations on retrospective reviews using a secure Internet connection. Issue Date: August 2017 Page 7

12 Section 5: Web-based Utilization Review Submissions KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance Responsibility Providers will attach all requested documentation via the QHPP web-based review system. Requirements The QHPP requires: Internet access Provider account setup Individual user registration Completion of training More information about the QHPP is on Qualis Health s website at: Process and Procedures Submission If you have already registered and received QHPP training from Qualis Health, search the QHPP for the case being reviewed, attach requested medical records via the Internet at Required Review Documentation Complete medical record Itemized billing with identified revenue codes UB-04 Medical Necessity Screening Once we receive all information needed for the review, a Qualis Health clinical reviewer assesses that information using established criteria to determine whether the condition of the recipient meets the Severity of Illness (SI) and Intensity of Service (IS) requirements for the services provided and the type and number of services requested. Second-level Peer Review When episodes do not meet the criteria, the clinical reviewer refers those episodes to a Qualis Health physician reviewer (medical director or P/PC) for clinical peer review. The physician reviewer evaluates the clinical information and either approves or denies the services reviewed. Issue Date: August 2017 Page 8

13 Section 5: Web-based Utilization Review Submissions KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance Time Frames The most common time frames for QHPP reviews are listed below. These time frames adhere to the KDHC-DHCF retrospective utilization review program and are measured beginning with the date of notification to the provider requesting submission of entire medical records to Qualis Health. Review Type Medical record request Retrospective review Technical Denial (TD) Reconsideration Time Frames Thirty (30) calendar days for the provider to submit the entire medical record with a reminder sent at 15 days Thirty (30) calendar days for Qualis Health to complete the review once the entire medical record is received Ninety (90) calendar days for the provider to submit the requested information from the date on the TD letter Thirty (30) calendar days to requests a reconsideration to Qualis Health from the date of the denial letter Issue Date: August 2017 Page 9

14 Section 6: Utilization Review Process Overview SECTION 6: UTILIZATION REVIEW PROCESS OVERVIEW Case Selection Categories Retrospective Review Types 1-2 Day Stays Ambulatory Surgery Cost Outliers Days Outlier ER Visit Single CC with 3 day or more LOS Multiple CC with 3 day or more LOS No CC with 3 day or more LOS Higher Weighted DRGs Hospital Outpatient Private Psychiatric Hospitals Readmission Description Short stay admissions reviewed to determine the medical necessity for inpatient care (excludes normal maternity and newborns) Cases involving ambulatory surgery performed in ambulatory surgery centers. Acute hospital admission where total charges have exceeded the Medicaid FFS defined trim point for the assigned DRG. Acute hospital admission in which the length of stay exceeds the Medicaid FFS defined trim point for the assigned DRG exceeding outlier status as defined by the Fiscal Agent. Hospital emergency room Review claims for appropriate code assignment when comorbid/complication code(s) are identified on the claim that impacts the DRG assignment. As above Review claims for appropriate code assignment that impacts the DRG assignment. Provider requests for higher-weighted DRGs. Outpatient procedures, Observation at hospitals Freestanding psychiatric facilities Hospital readmissions that occur within thirty calendar days after discharge from the same or another hospital. Review in each category above includes verification that medical necessity and professionally recognized standards of care have been met as well as to validate that the episode of care is billed in compliance with KDHE policies and coverage guidelines. Issue Date: August 2017 Page 10

15 Section 6: Utilization Review Process Overview DRG Validation Review DRG Validation Review is to determine if the diagnostic and procedural information that led to the DRG assignment is correct and substantiated in the medical record. Qualis Health uses 3M DRG Coding Validation Software. When the diagnoses/procedures, as shown on the claim, are not substantiated by the clinical documentation in the medical record, the Clinical Reviewer will refer the case to a Qualis Health physician reviewer for a determination. If the diagnosis and/or procedure information is determined to be incorrect by the Qualis Health physician reviewer, the diagnoses/procedures will be revised to a new DRG. This action may result in either additional payment or recoupment of the difference in payment, depending on the outcome of the DRG validation determination. First-level Non-physician Review The first-level review process begins when all requested documentation is received by Qualis Health. A clinical reviewer then performs the review using InterQual medical necessity criteria and 3M DRG Validation Software. InterQual criteria are based on well-researched medical evidence that is reviewed and updated annually by McKesson. Additionally we utilize the same version of 3M DRG Validation Software that the state is currently using. If medical necessity, appropriateness of the level of care and for inpatient episodes, appropriate DRG coding can be established through the application of these criteria, the clinical reviewer approves the retrospective review and notifies the requestor via QHPP. If appropriate level of care and/or medical necessity criteria or DRG validation is not met, secondary medical review is required and the case is referred to a Qualis Health physician reviewer. Second-level Peer Review The Qualis Health physician reviewer evaluates the information they have received and uses their specialty expertise and clinical judgment to make the second-level review determination. The physician reviewer has up-to-date reference materials and guidelines available to help ensure their review determination is founded on current evidence-based best practices and accepted standards of practice. If the second level peer reviewer approves the retrospective review, Qualis Health will notify the provider via QHPP. If the services are denied, you will receive a letter via fax or mail from Qualis Health, with reconsideration and fair hearing rights. Issue Date: August 2017 Page 11

16 Section 7: Retrospective Utilization Review KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance SECTION 7: RETROSPECTIVE UTILIZATION REVIEWS Definition and Purpose A retrospective review is a review for medical necessity after services have been rendered and the patient has been discharged. Each month, Qualis Health will receive data from the fiscal agent identifying paid claims in the preceding month. Cases eligible for selection will include original and adjusted claims. Qualis Health will initiate review activities by selecting the cases to be reviewed during the next monitoring period and notifying the hospitals to make available those medical records that have been selected. Retrospective reviews are necessary to determine medical necessity, standard of care provided and to validate that the episode of care is billed in compliance with KDHE policies and coverage guidelines. Responsibility Providers will submit all required review documentation via the QHPP. Qualis Health must receive all required review documentation to satisfy criteria before we certify a retrospective review. Process and Procedures Operational hours for Kansas Medicaid reviews are Monday through Friday, 8:00 am to 5:00 pm CST, excluding scheduled holidays. Designated provider personnel will submit all required review documentation to Qualis Health via the QHPP. QHPP UM Phone (877) UM Fax (877) Mail ksproviderportal@qualishealth.org Qualis Health PO Box 5268 Topeka, KS If you call after business hours, you may leave a confidential voic (Qualis Health s voice mail system is available 24 hours a day). We will return messages left after regular business hours the next business day. Issue Date: August 2017 Page 12

17 Section 8: Potential Quality of Care Concerns KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Ccare Finance SECTION 8: POTENTIAL QUALITY OF CARE CONCERNS Qualis Health is committed to promoting optimum quality of care for all recipients in keeping with generally accepted standards of practice. Therefore, we assess quality of care in various settings while performing reviews. The facility and attending physician are responsible for delivering the utmost quality of care for their patients. The Qualis Health clinical reviewer is responsible for identifying potential quality of care concerns regarding Kansas Medicaid recipients. If the Qualis Health clinical reviewer identifies a potential quality of care concern when performing a review they consult a Qualis Health physician. If the Qualis Health physician concurs that there is a potential quality of care concern, Qualis Health refers the case to KDHE-DHCF for further action. Issue Date: August 2017 Page 13

18 Section 9: Reconsideration and State Fair Hearings SECTION 9: RECONSIDERATION AND ADMINISTRATIVE STATE FAIR HEARINGS When a review determination is to deny or to adjust a inpatient DRG, Qualis Health generates written notification of the adverse decision within one (1) business day of the date the decision is made. The denial notification letter includes rights for reconsideration to Qualis Health as well as for requesting an Administrative Fair Hearing. If the reconsideration or fair hearing request is not received according to the procedure outlined in the denial letter, this determination will become final within thirty (30) calendar days from the date on the letter. When the determination becomes final, the amount paid for the denied services will be recouped. Reconsideration, Administrative Hearings, and Support A. Reconsideration/Re-review The purpose of the Qualis Health reconsideration process is to allow the hospital or attending physician an opportunity for a reconsideration/re-review when dissatisfied with an adverse review determination. A written request for reconsideration provides an opportunity to include additional medical justification that was not provided during the initial review process. The entire medical record is requested to perform the initial review, therefore, please do not resend documents that are already present in the Qualis Health Provider Portal (QHPP) case. The reconsideration process applies when the admission or invasive procedure is reduced or denied. Requests based on eligibility or coverage issues are not eligible for reconsideration. The reconsideration review will be performed by a different physician reviewer from the physician reviewer who made the initial review determination. Process Timeframes A request for reconsideration must be submitted in writing to Qualis Health within thirty (30) calendar days from the date of the denial notice. Issue Date: August 2017 Page 14

19 Section 9: Reconsideration and State Fair Hearings Request and Content A request for reconsideration can be made by faxing the information below with any additional substantiating medical information to (877) Any party notified of the denial determination may request a reconsideration and the request must be submitted in writing to Qualis Health, including the following information: a) Patient's name and Medicaid ID number b) Facility name and dates of service c) Reason for the request, and d) New information not previously received to support opinion. Notification Following completion of reconsideration activity, a written notice of the determination will be sent to the facility and the attending physician. The written notice will contain the rationale for the reconsidered determination and a statement informing the parties of their fair hearing rights. The determination of a reconsideration is final and effective on the date of the letter. Should you disagree with a reconsideration determination that upholds a denial determination, a fair hearing may be filed with the State of Kansas, Department of Administration, Office of Administrative Hearings. B. Administrative Fair Hearing The State of Kansas provides Administrative Fair Hearings as a mechanism for facilities and physicians if Qualis Health's denial determinations are questioned by the facility or the attending physician. To request an Administrative Fair Hearing pursuant to K.A.R et seq., submit your written request within thirty (30) calendar days, plus three (3) days for mailing, from the date of the final determination notice. The written request should be received by the State of Kansas, Department of Administration, Office of Administrative Hearings, 1020 South Kansas Avenue, Topeka, Kansas Issue Date: August 2017 Page 15

20 Section 9: Reconsideration and State Fair Hearings Confidentiality of Medical Records Submission Qualis Health and our QHPP are in compliance with all Federal and KDHE security and confidentiality regulations. Please do not protected health information (PHI) to Qualis Health. For security of PHI and for efficiency of the review process we encourage the use of the secure QHPP for submission of medical records and for communication with Qualis Health about cases under review. Issue Date: August 2017 Page 16

21 Appendices Qualis Health Appendices KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance UM Retrospective Review Services Provider Manual Issue Date: August 2017 Page 17

22 Appendices This page intentionally blank Issue Date: August 2017 Page 18

23 Appendix A - KMAP Hospital DRG Weights & Limits KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Ccare Finance APPENDIX A: KMAP HOSPITAL DRG WEIGHTS & LIMITS LINK Go to the Kansas Medical Assistance Program web page: Under Provider, scroll down to Interactive Tools o Then select: Hospital DRG Weights and Limits Issue Date: August 2017 Page 19

24 Appendix B - KDHE-DHCF and KMAP Key Links APPENDIX B: KDHE-DHCF AND KMAP LINKS KDHE-DHCF: Home Page - KMAP: Provider page: KMAP Provider Manual: KMAP Appeal Rights: Issue Date: August 2017 Page 20

25 Appendix C Qualis Health Key Contacts KDHE-DHCF: Kansas Department of Health and Environment - Division of Health Care Finance APPENDIX C: KEY CONTACTS FOR QUALIS HEALTH Qualis Health Contact Information PO Box 5268 Topeka, KS Phone: (877) FAX: (877) Administration Patricia Counter, RN, BSN, CCM, ACM Director, Kansas Medicaid Services (800) ext patriciac@qualishealth.org Cara Robinson, RN, BSN, CCM Vice President, Care Management (800) ext carar@qualishealth.org Issue Date: August 2017 Page 21

26 Appendix D Process Flow Charts APPENDIX D: PROCESS FLOW CHART Issue Date: August 2017 Page 22

27 Appendix D Process Flow Charts Issue Date: August 2017 Page 23

28 Appendix D Process Flow Charts This page intentionally blank Issue Date: August 2017 Page 24

29 APPENDIX E: LETTER 1 - ADJUSTED DRG August Letters Page 25

30 Adjusted DRG Page 2 August Letters Page 26

31 Adjusted DRG Page 3 August Letters Page 27

32 APPENDIX E: LETTER 2 - DENIAL August Letters Page 28

33 Denial Page 2 August Letters Page 29

34 Denial Page 3 August Letters Page 30

35 APPENDIX E: LETTER 3 DENIAL OP August Letters Page 31

36 Denial-OP Page 2 August Letters Page 32

37 Denial-OP Page 3 August Letters Page 33

38 APPENDIX E: LETTER 4 MEDICAL RECORD REQUEST 1 August Letters Page 34

39 MEDICAL RECORD REQUEST 1 Page 2 August Letters Page 35

40 MEDICAL RECORD REQUEST 1 Page 3 August Letters Page 36

41 APPENDIX E: LETTER 5 - MEDICAL RECORD REQUEST 1-OP August Letters Page 37

42 MEDICAL RECORD REQUEST 1-OP Page 2 August Letters Page 38

43 MEDICAL RECORD REQUEST 1-OP Page 3 August Letters Page 39

44 APPENDIX E: LETTER 6 - MEDICAL RECORD REQUEST 2 August Letters Page 40

45 MEDICAL RECORD REQUEST 2 Page 2 August Letters Page 41

46 MEDICAL RECORD REQUEST 2 Page 3 August Letters Page 42

47 APPENDIX E: LETTER 7 - MEDICAL RECORD REQUEST 2-OP August Letters Page 43

48 MEDICAL RECORD REQUEST 2-OP Page 2 August Letters Page 44

49 MEDICAL RECORD REQUEST 2-OP Page 3 August Letters Page 45

50 APPENDIX E: LETTER 8 RECONSIDERATION MODIFY August Letters Page 46

51 RECONSIDERATION MODIFY Page 2 RECONSIDERATION MODIFY Page 3 August Letters Page 47

52 APPENDIX E: LETTER 9 RECONSIDERATION MODIFY-OP August Letters Page 48

53 RECONSIDERATION MODIFY-OP Page 2 RECONSIDERATION MODIFY-OP Page 3 August Letters Page 49

54 APPENDIX E: LETTER 10 RECONSIDERATION REVERSE August Letters Page 50

55 RECONSIDERATION REVERSE Page 2 August Letters Page 51

56 APPENDIX E: LETTER 11 RECONSIDERATION REVERSE OP August Letters Page 52

57 RECONSIDERATION REVERSE-OP Page 2 August Letters Page 53

58 APPENDIX E: LETTER 12 RECONSIDERATION UPHOLD August Letters Page 54

59 RECONSIDERATION UPHOLD Page 2 RECONSIDERATION UPHOLD Page 3 August Letters Page 55

60 APPENDIX E: LETTER 13 RECONSIDERATION UPHOLD-OP August Letters Page 56

61 RECONSIDERATION UPHOLD-OP Page 2 RECONSIDERATION UPHOLD-OP Page 3 August Letters Page 57

62 APPENDIX E: LETTER 14 REQUEST FOR INFORMATION August Letters Page 58

63 REQUEST FOR INFORMATION Page 2 August Letters Page 59

64 REQUEST FOR INFORMATION Page 3 August Letters Page 60

65 APPENDIX E: LETTER 15 REQUEST FOR INFORMATION-OP August Letters Page 61

66 REQUEST FOR INFORMATION-OP Page 2 August Letters Page 62

67 REQUEST FOR INFORMATION-OP Page 3 August Letters Page 63

68 APPENDIX E: LETTER 16 TECHNICAL DENIAL August Letters Page 64

69 TECHNICAL DENIAL Page 2 TECHNICAL DENIAL Page 3 August Letters Page 65

70 TECHNICAL DENIAL Page 4 August Letters Page 66

71 APPENDIX E: LETTER 17 TECHNICAL DENIAL-OP August Letters Page 67

72 TECHNICAL DENIAL-OP Page 2 TECHNICAL DENIAL-OP Page 3 August Letters Page 68

73 TECHNICAL DENIAL-OP Page 4 August Letters Page 69

74 August Letters Page 70