Quality Insights of Pennsylvania

 Review ServicesThe Quality Insights Review Department reviews the medical records of Medicare beneficiaries as part of its contract with the Centers for Medicare & Medicaid Services (CMS). In reviewing medical records, Quality Insights is looking at whether care meets these standards:

• Does it meet medically accepted standards of care?
• Is it medically necessary?
• Is it delivered in the most appropriate setting?

Quality Insights employs non-physician and physician reviewers and maintains a roster of board-certified specialists to assess clinical care. Quality Insights began using the 2008 InterQual criteria in August 2008.

The following links provide more details about reviews and other activities.

• Beneficiary Protection, including the following:
• HINN (Hospital Issued Notice of Noncoverage)
• IM (Important Message Hospital Discharge Appeal)
• BIPA (Benefits Improvement and Protection Act Appeal)
• MA (Medicare Advantage Appeals)
• Beneficiary Complaints
• Emergency Medical Treatment and Labor Act (EMTALA)
• Higher Weighted DRG Review (HWDRG)

Changes to appeals Some changes in Beneficiary Notifications and Appeal Rights took effect July 2007. The following information and resources are available:

• Hospital Discharge Appeal Notices section of the CMS Web site
• Hospital Discharge Appeal Rights, PowerPoint presentation
• A form for providers to submit their Contact Information for Medicare Appeals to - Complete and fax to Quality Insights

Watch this site for more information.

If you have questions about a topic not listed, contact Quality Insights.