Medicare Case Review

If you are a Medicare beneficiary or caregiver and need information on your rights or instructions on how to file a quality of care complaint or appeal click here click here.

TMF Health Quality Institute (TMF) is authorized by the Medicare program as the quality improvement organization (QIO) for Texas to review medical care and services provided to Medicare beneficiaries. By law, TMF reviews these cases to determine if the services provided meet medically acceptable standards of care, are medically necessary, and are delivered in the most appropriate setting.

Reviews are conducted under the auspices of the TMF State Review Program Committee (SRPC). The SRPC evaluates utilization/quality concerns identified as a result of TMF's individual case review. The committee evaluates patterns of statewide practice variation, provides feedback and suggestions for improving practice patterns to the health care community, and monitors to ensure resolution of issues on an ongoing basis. TMF may refer the responsible party for the issue to the Centers for Medicare & Medicaid Services (CMS) or the Office of the Inspector General when issues are egregious or not resolved after time and effort to correct them has been spent.

For information on how to become a TMF physician reviewer, click here.