QIO's are required to perform individual case review to fulfill mandatory review
requirements (See ยง4100). Mandatory review categories include: alleged anti-dumping
violations, requests for assistants at cataract surgery for specific codes, beneficiary
complaints, beneficiary's request for immediate review of hospital discharge,
hospital-requested higher-weighted Diagnosis Related Groups (DRG) adjustments,
potential gross and flagrant violations in one or more instances or substantial violations in
a substantial number of cases (See Chapter 9), and Hospital Payment Monitoring
Program (HPMP) cases (See Chapter 11).
