Medical Review

HealthInsight New Mexico (formerly NMMRA) is the only federally-designated organization in New Mexico that performs peer review. In addition, HealthInsight New Mexico is the designated External Quality Review Organization for New Mexico.

Medicare Case Review

Under CMS regulations and guidelines, medical cases come to HealthInsight New Mexico for review from various sources:

• Quality of care concerns and complaints
• Hospital Discharge Reviews
• Pre-admission/Admission Hospital Issued Notice of Non-Coverage Reviews
• Notice of Non-Coverage Appeals
• Alleged Emergency Medical Treatment and Active Labor Act (EMTALA) Violations
• Hospital Requested Higher-Weighted Diagnosis-Related Group (DRG) Assignments

All medical review done by HealthInsight New Mexico requires evaluation of the medical record of the Medicare beneficiary. HealthInsight New Mexico may review cases for quality of care, appropriateness of discharge, proper utilization and correct DRG assignment. Cases submitted to physician review for determination are conducted by reviewers with qualifications to practice medicine, an active license to practice, and good standing in the community.

External Quality Review (EQR)

HealthInsight New Mexico performs external quality review for state contractors. These reviews include:

• Utilization managment denials
• Grievance and appeals
• Care coordination/case management
• Transition of care
• Individuals with Special Health Care Needs (ISHCN)
• Performance measures
• Performance improvement projects