Update on Medicare Case Review

The Centers for Medicare & Medicaid Services (CMS) has made significant changes to its national Quality Improvement Organization (QIO) program. Under the new program structure, QIOs are not permitted to serve both the case review and quality improvement roles. The TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO) has the health care quality improvement role and therefore is not participating in case review, referred to as Beneficiary and Family Centered Care.

As of August 1, 2014, KePRO is the new Beneficiary and Family Centered Care QIO (BFCC-QIO) for Texas, Arkansas, Missouri and Oklahoma, and Livanta is the BFCC-QIO for Puerto Rico. These organizations are responsible for protecting the quality and safety of care delivered to Medicare beneficiaries. Appeals submitted and pending as of August 1, 2014 do not need to be resubmitted.

These changes are part of the CMS QIO program transformation effort to further enhance the quality of services to Medicare beneficiaries. Health care providers and Medicare beneficiaries in Texas, Arkansas, Missouri and Oklahoma must contact KePRO toll-free at 1-844-430-9504, and health care providers and Medicare beneficiaries in Puerto Rico must contact Livanta toll-free at 1-866-815-5440 for all appeal requests and quality of care concerns. All outstanding Higher-Weighted DRG medical record requests should be mailed to:

Texas, Arkansas, Missouri and Oklahoma:
KePRO Rock Run Center 5700 Lombardo Center, Suite 100 Seven Hills, Ohio 44131 Call toll-free at 1-844-430-9504

Puerto Rico:
Livanta BFCC-QIO Program 9090, Junction Drive, Suite 10, Annapolis Junction, MD 20701

If you have any questions you can email CMS directly at QIOProgram@cms.hhs.gov. In addition, CMS is planning an Open Door Forum for providers. View more information about the Open Door Forum and the changes to the QIO program.

Texas • Arkansas • Missouri • Oklahoma • Puerto Rico