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Mandatory/HINN Review

Our goals in Mandatory review include:

• Improving quality of care for beneficiaries by ensuring that beneficiary care meets recognized standards of health care.

• Protecting the integrity of the Medicare trust fund by ensuring that Medicare only pays for services and items that are reasonable and medically necessary and are provided in the most economical setting.

• Protecting beneficiaries by expeditiously addressing individual cases such as beneficiary complaints, hospital issued notices of noncoverage (HINNs), Emergency Medical Treatment and Active Labor Act (EMTALA) violations (dumping), and other statutory responsibilities.

Ohio KePRO is required to perform individual case review to fulfill mandatory review requirements. Mandatory review categories include: alleged anti-dumping violations, beneficiaries complaints, hospital notices of noncoverage, beneficiaries requests for immediate review of Medicare Advantage (MA) organization-issued notices of noncoverage, hospital-requested higher-weighted DRG adjustments, assistant surgeons during cataract surgery,  potential gross and flagrant violations, and referrals.

• HINN

• Medical Director Presentation

 

• HPMP

• Physician Reviewers