Medicare Case Review


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. TMF has elected to focus on quality improvement activities and therefore did not pursue the case review contract, referred to as the Beneficiary and Family Centered Care QIO contract.

As of August 1, 2014, KePRO will be the new Beneficiary and Family Centered Care QIO (BFCC-QIO) in Texas and will work to protect the quality and safety of care delivered to Medicare beneficiaries. TMF will work to ensure a smooth transition and will use our relationships to secure appropriate introductions and support with KePRO. To avoid processing delays and errors, please continue submitting cases and requests to TMF Health Quality Institute through Thursday, July 31, 2014, using your current process.

These changes are part of the Centers for Medicare & Medicaid Services (CMS) QIO program transformation effort to further enhance the quality of services to Medicare beneficiaries. If your case is currently under review or in process, please be assured that every effort has been made to ensure a seamless transition for Medicare beneficiaries with no disruption in case review services.
Beginning Friday, August 1, 2014, health care providers and Medicare beneficiaries must contact KePRO toll-free at 1-844-430-9504 for all appeal requests and Quality of Care concerns. All outstanding Higher-Weighted DRG medical record requests after the above date should be mailed to:
Rock Run Center
5700 Lombardo Center, Suite 100
Seven Hills, Ohio 44131

If you have any questions you can email CMS directly at 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.

If you are a Medicare beneficiary or caregiver and need information on your rights or instructions on how to file a quality of care complaint or request a discharge/termination of service review, click here.

Through July 31, 2014, TMF Health Quality Institute is authorized by the Medicare program as the quality improvement organization (QIO) for Texas to review medical care and services provided to Medicare beneficiaries. By law, TMF reviews these cases to determine if the services provided meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting.

Reviews are conducted under the auspices of the TMF State Review Program Committee (SRPC). The SRPC evaluates utilization/quality concerns identified as a result of TMF's individual case review. The committee evaluates patterns of statewide practice variation, provides feedback and suggestions for improving practice patterns to the health care community, and monitors to ensure resolution of issues on an ongoing basis. TMF may refer the responsible party for the issue to the Centers for Medicare & Medicaid Services (CMS) or the Office of the Inspector General when issues are egregious or not resolved after time and effort to correct them has been spent.

Case review information:

Bridgepoint I Suite 300 | 5918 West Courtyard Drive | Austin, Texas 78730-5036 | Phone 1-800-725-9216 | Fax 512-327-7159 | Email
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