Medicare Case Review

As the New Jersey Quality Improvement Organization, HQSI is responsible for conducting Medicare reviews in New Jersey. 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:

• Medically necessary
• Provided in the most appropriate setting
• Of a quality that meets professionally recognized standards of care

Case reviews are generated from multiple sources, including:

• Medicare beneficiaries or their designated representatives
• Centers for Medicare & Medicaid Services and/or the Center for Medicare & Medicaid Services-designated agencies
• Providers

The types of reviews HQSI performs include:

• Quality of Care
• Utilization Review
• Diagnosis Related Group Validation