Other Reviews

Overview

Acentra Health is responsible for other mandatory reviews as part of its a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contract with the Centers for Medicare & Medicaid Services (CMS).

These other reviews are

• EMTALA reviews
• Referral reviews
• Assistant at Cataract reviews

EMTALA

Acentra Health conducts a five-day medical advisory review upon request from the appropriate CMS regional office. Acentra Health’s physician conducts a medical assessment of a potential Emergency Medical Treatment and Labor Act (EMTALA) violation case as specified in Part 9 of the QIO Manual (Attachment J-4) (PDF). The regional office may use this review as a resource in making a compliance determination.

For more information, visit CMS’ Quality, Safety and Education Portal (QSEP) at qsep.cms.gov or visit the EMTALA page on the CMS website.

Under sections 1867(d)(3) of the Act and 42 CFR §489.24(g), Acentra Health is required to conduct a 60-day review upon receipt of a completed EMTALA case sent to the Office of the Inspector General for possible civil monetary penalty or exclusion sanction as outlined in Part 9 of the QIO Manual.

Referral Reviews

BFCC-QIOs are required to conduct quality reviews when complaints about Medicare beneficiaries' healthcare are received from sources other than the beneficiary. These referrals come from a variety of state and federal agencies and organizations that include, but are not limited to:

• CMS;
• the Office of the Inspector General (OIG);
• the Federal Bureau of Investigation (FBI);
• the Centers for Health Dispute Resolution (CHDR);
• the Joint Commission; and
• Medicare Administrative Contractors (MAC).