As the New Jersey Quality Improvement Organization (QIO), Healthcare Quality Strategies, Inc., (HQSI) is responsible for conducting Medicare reviews in New Jersey. Under the 9th SOW, CMS refers to this as the Beneficiary Protection Theme. Federal laws and regulations stipulate the types of reviews we perform and the methods for how they are conducted. The purpose of case review is to ensure that services provided to Medicare beneficiaries are:

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• Medically necessary

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• Provided in the most appropriate setting

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• Of a quality that meets professionally recognized standards of care

Case reviews are generated from multiple sources, including:

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• Medicare beneficiaries or their designated representatives

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• CMS and/or CMS-designated agencies

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• Providers

The types of reviews HQSI performs include:

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• Quality of Care

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• Utilization Review

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• DRG Validation

Medicare Discharge Appeals
HQSI is responsible for the Medicare Discharge Appeals Process. Access a step-by-step introduction to this process, Medicare Discharge Appeals Process Handouts from Conference Call/WebEx (February 25, 2009).

Physician Acknowledgement Statement Monitoring
HQSI monitors hospital compliance with Physician Acknowledgement Statements. The Centers for Medicare & Medicaid Services (CMS) require that hospitals annually submit a list of physicians granted admitting privileges in the prior calendar year (see Code of Federal Regulations (CFR) for further information). In addition, hospitals are required to have a signed acknowledgement statement from each physician with new admitting privileges (newly credentialed) prior to his/her first admission to the hospital or first claim submission.

Hospitals should print out, complete, and then return the 2009 Physician Acknowledgement spreasheet (available with instructions) to HQSI, along with a photocopy of the signed and dated physician acknowledgement statement for each newly credentialed physician.

Annual Report
HQSI publishes an annual report on our website summarizing review activities in accordance with a template required by CMS.