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  3. Peer Review Organization (PRO) Quality Improvement Organization (QIO)

Peer Review Organization (PRO) / Quality Improvement Organization (QIO) 

State Medicaid agencies are required to provide quality assurance and fee-for-service utilization review in the inpatient hospital settings for services provided to participants in the Medical Assistance program and Illinois contracts with a PRO/QIO to conduct this function. The department requires the PRO/QIO to assist the department in assuring that quality care is being provided to Medical Assistance program participants.

Effective June 1, 2006, the department executed a contract with Health Systems of Illinois (HSI). HSI provides concurrent, retrospective prepayment and post payment reviews for services provided in the inpatient hospital setting for participants eligible for Medical Assistance. HSI provides quality of services review including medical necessity, reasonableness and appropriateness of care using telephonic, and web-based interactions. Please view HSI’s Web site for additional information. Please view the Department of Healthcare and Family Services Web site for provider releases and policy updates.

Below are documents containing Attachments A, B, C, and D. These attachments list the diagnosis and DRG codes subject to utilization review.

Attachments

The department requires an External Quality Review Organization (EQRO) to provide quality assurance oversight for Managed Care Organizations under contract with the department. Effective June 1, 2006, the department executed a contract with Health Services Advisory Group (HSAG) which is a qualified EQRO to provide external, independent quality assurance oversight including quality outcomes and timeliness of, and access to, services of managed care. HSI’s Web site contains additional information on HSAG.

Links with additional managed care information: