To protect the rights and health of Medicare beneficiaries, OFMQ reviews the following types of cases:

Review of Notices of Medicare Non-Coverage – Providers and health plans are required to issue a notice of non-coverage when they determine medical care is no longer necessary. A beneficiary may exercise his/her federal right to dispute the termination of service decision by requesting a review from OFMQ. The purpose of our review is to ensure that the notice is correct and that beneficiaries or managed care enrollees are not discharged prematurely from care or have services discontinued prematurely. Non-coverage cases we review are:

Hospital Issued Notice of Non-Coverage (HINN) – issued by a hospital to Original Medicare (fee-for-service) beneficiaries

Notice of Discharge and Medicare Appeal Rights (NODMAR) – issued by a managed care organization to Medicare Advantage health plan members

Expedited Review of Termination of Service Appeals (BIPA appeals) – An Original Medicare beneficiary may request an expedited appeal to dispute a termination of service decision by a Medicare-covered comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), hospice, swing bed or skilled nursing facility (SNF).

Medicare Advantage Immediate Appeals (Grijalva appeals) – A Medicare Advantage beneficiary may request a “fast track appeal” for a Notice of Medicare non-coverage for care in a SNF or CORF, or by a home health agency. A healthcare provider may also appeal on behalf of a beneficiary.

Examination and Treatment for Emergency Medical Conditions and Women in Active Labor (EMTALA) – Hospital emergency departments are required by law to provide appropriate medical care to anyone in need, regardless of ability to pay. OFMQ may be called in for review of potential violations and reporting to CMS. Hospitals may be penalized for non-compliance. 

Other Case Review – OFMQ reviews individual cases received from a variety of sources to determine medical necessity, quality of care, and/or DRG validation determinations (applicable to the kind of case under review). The activities include all hospital-requested higher weighted DRG assignment cases accepted by the Fiscal Intermediaries (FIs), coverage decision referrals from FIs, and any other review required by CMS. These include reconsiderations for quality of care concerns, DRG changes, admission denials, readmission reviews, day outliers, and administrative law judge hearings. OFMQ also monitors hospital compliance in securing physician acknowledgment statements.