Expectations of Provider Reviews Missouri Medicaid Audit & Compliance Unit (MMAC) Provider Enrollment Contracts & Terminations Provider Review & Lock-in.

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Presentation transcript:

Expectations of Provider Reviews

Missouri Medicaid Audit & Compliance Unit (MMAC) Provider Enrollment Contracts & Terminations Provider Review & Lock-in Investigations

Provider Review & Lock-in Section Monitor Participant Service Utilization Monitor Provider Program Compliance Pre-Enrollment Site Visits

Review location Review policies and documentation Additional questions

Provider Reviews Record Retention ◦As required by 13 CSR (3)(A)4 On-Site and desk reviews On-Site Reviews Entrance Client and personnel record reviews Staff Interviews Client Interviews Exit Questions

Review of Records Adequate Documentation ◦Defined in 13 CSR (2)(A) Time Sheets/Telephony Records Nursing Notes Training Records Employee Records Other program requirements

Outcome of Record Review Findings Letter and Attachment Plan of Correction ◦Steps to Correct ◦Person Responsible ◦Date to be implemented Possible Sanctions (13 CSR (4)) ◦Overpayment ◦Suspension or Termination of MO HealthNet Number

Helpful Links MO HealthNet Website – MMAC Website – MO HealthNet Provider Manuals – Code of State Regulations –

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