Administrative Memos

200102

FROM: Theodore O. Will, Chief Executive Officer
DATE: Feb 21, 2002
SUBJECT: Medicaid Peer Review Process
IPRO CONTACTS:

Kathleen M. Fox, Director of Medicaid Review Operations Extension 361

This memorandum describes the Medicaid review criteria and process used by IPRO, the New York State Medicaid UR agent, along with its subcontractor, the Empire State Medicaid Scientific and Education Foundation (The Foundation), when conducting utilization review activities. Selected cases have the following reviews conducted where appropriate:

DRG validation, using ICD-9 coding guidelines.
Utilization review, using InterQual criteria for admission and continued stay, as well as SIM Plus criteria for surgical indications and invasive procedure monitoring.
Quality of care review, using the structured integrated Medicaid Reviewer Assessment Format (MRAF), which is a method of categorizing decisions made by reviewers. A quality concern may be categorized as an immediate concern, which represents a significant departure from generally, recognized standards of care and is linked to adverse patient outcomes. Other quality concerns may be defined as omission(s) or commission(s) in the provision of care, which have the potential to result in adverse effects on patients.

The information, which follows, describes (1) the Medicaid Review process, (2) the Documentation Review process, and (3) the "Immediate Concerns" Quality Issues process.