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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.
The department has executed a contract with eQHealth Solutions (eQH). eQH provides concurrent, retrospective prepayment and post payment reviews for services provided in the inpatient hospital setting for participants eligible for Medical Assistance. eQH provides quality of services review including medical necessity, reasonableness and appropriateness of care using telephonic, and web-based interactions. Please view eQHealth Solutions' (eQH) website 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, D, E and F. These attachments list the diagnosis and DRG codes subject to utilization review.
Attachments
- Attachments A-F Diagnosis, Procedure, and DRG Codes Subject to Utilization Review Beginning 10-01-23 Updated 05-24-24 (pdf)
- Attachments A-F Diagnosis, Procedure, and DRG Codes Subject to Utilization Review Beginning 01-01-22 (pdf)
- Attachments A-F Diagnosis, Procedure, and DRG Codes Subject to Utilization Review Beginning 01-01-20 (pdf)
- Attachments A-F Diagnosis, Procedure, and DRG Codes Subject to Utilization Review Beginning 01-01-20 (pdf)
- Attachments A-F Diagnosis, Procedure, and DRG Codes Subject to Utilization Review Beginning 01-01-19 (pdf)
- Attachments A-F Diagnosis, Procedure, and DRG Codes Subject to Utilization Review Beginning 12-01-17 through 12-31-18 (pdf)
- Attachments A-F Diagnosis, Procedure, and DRG Codes Subject to Utilization Review Beginning 10-01-16 through 11-30-17 (pdf)
- Attachments A-F Diagnosis, Procedure, and DRG Codes Subject to Utilization Review Beginning 10-01-15 (pdf)
- Attachments A-F Diagnosis and DRG Codes Subject to Utilization Review Beginning 07-01-14 through 09-30-15 (pdf)
- Attachments A-F Diagnosis and DRG Codes Subject to Utilization Review Beginning 04-01-14 through 06-30-14( pdf)
- Attachments A-E Diagnosis and DRG Codes Subject to Utilization Review Beginning 10-01-13 through 03-31-14 (pdf)
- Attachments A-D Diagnosis and DRG Codes Subject to Utilization Review Beginning 07-01-13 through 09-30-13 (pdf)
- Attachments A-D Diagnosis and DRG Codes Subject to Utilization Review Effective 08-01-12 through 06-30-13 (pdf)
- Attachments A-D Diagnosis and DRG Codes Subject to Utilization Review Effective 01-01-10 through 07-31-12 (pdf)
- Attachments A-D Diagnosis and DRG Codes Subject to Utilization Review Effective 11-01-08 through 12-31-09 (pdf)
- Attachments A-D Diagnosis and DRG Codes Subject to Utilization Review Effective 06-01-08 through 10-31-08 (pdf)
- Attachments A-D Diagnosis and DRG Codes Subject to Utilization Review Effective 03-01-07 through 05-31-08 (pdf)
- Attachments A-D Diagnosis and DRG Codes Subject to Utilization Review Effective 12-01-05 through 02-28-07 (pdf)
- Attachments A-D Diagnosis and DRG Codes Subject to Utilization Review Effective 05-01-05 through 11-30-05 (pdf)
- Attachments A-D Diagnosis and DRG Codes Subject to Utilization Review Effective 01-01-05 through 04-30-05 (pdf)
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.