Northeast Health Care Quality Foundation
The QIO for Maine, New Hampshire and Vermont
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QIO TRANSMITTAL SERIES ISSUE: Required Review Activities - Printable pages Under the Eighth Scope of Work beginning August 1, 2005 in Maine, New Hampshire and Vermont, NHCQF is responsible for individual case review of the following categories of cases:
Category of Review	Type of Review
Potential EMTALA violations (patient dumping)	Quality Review
Assistants at Cataract Surgery	Utilization Review (medical necessity of a physician assistant at cataract surgery)
Beneficiary Complaints	Quality Review
Hospital Requested Higher Weighted DRG Adjustments	DRG Validation and Utilization Review (medical necessity of admission)
Notices of Noncoverage issued by acute care general hospitals	Utilization Review (medical necessity of admission and appropriateness of noncoverage notice)
Notices of Noncoverage issued by specialty hospitals, SNF swing beds and managed care plans (patient/patient representative requested reviews only)	Utilization Review (medical necessity of admission, length of stay review and appropriateness of noncoverage notice)
Notices of Noncoverage issued by SNF swing beds, SNFs, HHAs, hospices and comprehensive outpatient rehab facilities	Notice Review (appropriateness of noncoverage notice)
Referrals from Clinical Data Abstraction Centers as part of the Hospital Payment Monitoring Program	DRG Validation and Utilization Review (medical necessity of admission and any procedures performed)
Referrals from the Centers for Medicare & Medicaid Services, Office of Inspector General, the Managed Care Appeals Contractor, Intermediaries, Carriers, or Clinical Data Abstraction Centers, Medicare Integrity Program Contractors, Program Safeguard Contractors or others	Review specific to the referral
Potential instances of gross or flagrant violations of professionally recognized standards of care	Quality Review
NHCQF’s review of cases in these review categories is limited to the review type specified above. However, if other potential concerns are identified during the course of the review, NHCQF will take the appropriate actions. June 2006 Next Chapter: Hospital Payment Monitoring Program
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