Case Review

As the QIO for the Carolinas, CCME is authorized by CMS to perform case reviews for both beneficiaries and providers. Primary case review categories include utilization review, quality of care review, review of beneficiary appeals of certain provider notices, and reviews of potential EMTALA cases. Medicare review is conducted on cases brought to our attention by beneficiaries, public inquiries, state and federal agencies, and other governmental/congressional referrals.

CCME conducts individual case review for Medicare beneficiaries when complaints or questions arise regarding the quality of care that was received. Requests for review of a complaint may be initiated by the beneficiary, or the designated responsible party, caregivers, Medicare fiscal intermediaries (Part A) or Medicare carriers (Part B), or CMS. Case review involves a detailed evaluation by nurses and coding specialists for potential quality of care issues (i.e., is it a quality of care issue) or utilization or coding (DRG assignment) issues and is subsequently referred to a physician for rendering of a medical opinion. Full case review may take as long as 165 days to complete the process.

For questions regarding appeals and beneficiary complaints, contact Rita Scott at rscott@scqio.sdps.org.