Appendix H Medicaid Administrative Review Overview | Medicaid

The MEQC program is a statutory requirement under Section 1903(u) of the Social Security Act. It requires States to annually provide an estimate of improper payments in Medicaid based on eligibility reviews of States' recipients. MEQC is directed at improving the quality of State eligibility determinations. In Georgia, the MEQC process is managed by DCH and reviews are conducted on a monthly basis. DCH QC reviews 400 case records per month. This is a State level review and is not a measurement of benefit or claim errors but is used to measure the overall quality of case work conducted by DFCS Medicaid case managers.

MEQC completes 150 desk reviews a month on LIM cases that are closed.

County staff are expected to take appropriate action in a timely manner as specified in the Communicator.

Counties wishing to rebut QC findings should send a request for rebuttal to: mpayne@dch.ga.gov. In the request, counties should include the following:

Payment Error Rate Measurement (PERM) is a Federal review overseen by the Center for Medicare and Medicaid Services (CMS), the Federal Medicaid oversight agency, which measures improper payments in Medicaid and the Children’s Health Insurance Program (CHIP) based on reviews of States' eligibility determinations of applicants and recipients. Each state is reviewed once every three years, with the entire country being reviewed in a given three-year period. The next PERM sample period for Georgia will start October 2012.

Cases for MEQC reviews are requested for the identified sample month on or around the 5th of each month. This request is sent to the DFCS Medicaid policy unit and the cases are screened in SUCCESS for their current location, COA and status of the case. The results are entered in an Excel spreadsheet and sorted by Region and county and includes the Load ID from STAT. Each Region is required to submit to the State Office Medicaid Unit a Case Record Request that includes:

Case records requests, including MEQC record requests, are sent to the primary and secondary contacts identified in the Region Case Record Request plan and to the Regional Management and Medicaid Field Program Specialists along with the due date specified by DCH. Case records are due to DCH by noon on the due date.

The county DFCS office for which the case is listed in SUCCESS as currently residing is responsible for returning the case record to DCH.

Cases should be checked prior to being sent in to ensure to the current volume is being sent; that documentation is complete; and that it has all received verification filed in it. Permanent verification should be pulled forward from any earlier volumes to current volume. If an action was completed in the review month by the Call Center which required verification, verification should be requested immediately from the Call Center and filed in the case record before forwarding to DCH.

The record should contain a cover sheet on where to return the record after the review is completed by DCH. Case records for different sample months should NOT be sent in the same package.

Five business days prior to the date due to DCH MEQC, each Region will report to the DFCS OFI Medicaid Unit that the case records have been sent to MEQC or why they have not been using the original spreadsheet sent for the Request. Each record will be annotated sent or not sent, with an explanation for why any record was not sent.

For case records that cannot be located, the Region must:

If the Medicaid unit does not hear from a Region by the close of business on the fifth business day prior to the due date of the records, the Regional Manager will be called the following business day requesting an explanation.

A case that is reviewed and found correct will be returned to the county which currently has the case in SUCCESS. The county which completed the action under review will get credit for a correct case.

When case records are requested for MEQC/PERM review that are still with the RSM Project-

The MEQC Citizenship/ID exception for such cases will be charged against the original county.

Records for the MEQC review should be sent to:

Melanee Payne (mpayne@dch.ga.gov)
Medicaid Quality Control Program Director
Department of Community Health
P.O. Box 1984
Atlanta, GA 30301

If using UPS as the carrier, send to:

Melanee Payne (mpayne@dch.ga.gov)
Medicaid Quality Control Program Director
Department of Community Health
2 Peachtree St., NW 39th Floor
Atlanta, GA 30303

PERM case record requests should be returned to:

PERM Records Clerk
Medicaid Quality Control Program
Department of Community Health
P.O. Box 1984
Atlanta, GA 30301

If you are sending by UPS, send to:

PERM Records Clerk
Medicaid Quality Control
Department of Community Health
2 Peachtree St., NW 39th Floor
Atlanta, GA 30303

Please attach a printout of the spreadsheet listing the case record(s) being returned with the case(s) highlighted.

Responses requested are to be sent via email within 15 calendar days to the DCH reviewer and copied to the Medicaid Unit Manager and designee. No hard copy response is required. The response must include:

Rebuttals of MEQC, PERM or LIM errors should be submitted as soon as possible but no later than 15 Calendar days from receipt of the error.

Rebuttals must be routed through the Region Medicaid FPS who should review to ensure the rebuttal is appropriate and correctly address policy.

For cases that were transferred to another county after the sample month and are determined to have an error in sample month:

The Georgia Department of Audits and Accounts will conduct yearly reviews on a randomly selected sample of cases. Auditors reviewing cases are looking for the following:

Findings from this review are shared with the Division of Family and Children Services and are generally not case specific.

A yearly single audit is conducted for DCH by the firm of Metcalf Davis, Mauldin & Jenkins. Included in the audit is a review of DFCS eligibility processes. Five counties are chosen for review with a total sample of 60 case records. This review is conducted July through August of each year. Findings from this review are shared with DCH and the Division of Family and Children Services and are generally not case specific.

County supervisors, administrative staff and Medicaid Program Specialists also review Medicaid records.

Each Medicaid supervisor should complete Medicaid Quality Checks on cases for members of his or her unit prior to being finalized in SUCCESS. The number of Quality Checks completed should be of a reasonable number but should not exceed 5 checks per month per worker in the unit.

The Medicaid Quality Check is a targeted review completed by a supervisor or other designated reviewer prior to the Medicaid case being completed in SUCCESS. The elements under review are based on error trends identified in the MEQC, LIM or PERM review process. Elements for review can also be identified based on County or Regional needs. The Quality check is intended to be flexible and adaptive in order to reflect current needs and trends rather than identify issues or trends from three to six months in the past.

The objective of the Medicaid Quality Check is to ensure cases are determined correctly prior to finalization and that AUs are issued the Medicaid benefits for which they are entitled. Other objectives include:

Targeted areas are read on a pass/returned basis. A case passes that has had all targeted areas of eligibility determined correctly in accordance with all relevant policy and procedures, including documentation standards. Cases which pass are those that can stand on their own in SUCCESS and the material in the case record without requiring additional explanation or documentation.

A case is returned as part of the Medicaid Quality Check when any element under review does not pass. There are no deficiencies. All targeted elements should be read even when an element does not pass.

There six general reasons for which a particular area may not pass a quality check. These are:

These reasons should be annotated on the Quality Check form and compiled and reported as part of the county’s monthly report of Case Review results.

A case that does not pass all targeted areas is subject to “return” and must be sent back to the case manager for correction prior to finalization. The reviewer should give the “return” an appropriate time frame in which to be resubmitted and subjected to another Quality Check.

Cases should be submitted for Quality Checks in a timely fashion to ensure completion within the applicable Standard of Promptness (SOP). Supervisors should select the cases for Quality Check and should NOT permit staff to select the cases to be checked. The supervisor should select a variety of case actions and COAs for review.

General guidelines for the current elements targeted in the Medicaid Quality check may be found in the Medicaid Quality Check Guidelines document.

County Program Directors (CPD), Economic Support Administrators (ESA) or Medicaid Program Specialists, in the absence of a CPD/ESA, should complete second level reviews. The sample size for second level reviews should be 5% of the total number of Quality Checks read per supervisor and/or unit (not to exceed 3 per unit or supervisor) monthly. Cases should be selected from all Quality Checks completed in the previous month. In counties with second level administrative positions, Program Specialists should review randomly selected second level reviews to ensure correctness and verify all required corrections were completed in a timely manner.

The objective of Administrative Reviews is to ensure that the Quality Check process is being followed correctly and that front-line reviewers are accurately reviewing the cases.

An Administrative review finding is either correct or incorrect, there are no deficiencies. A correct case is one in which the front-line reviewer correctly determined “pass” or “fail” on the Medicaid Quality Check. For Children in Placement review requirements please ref

For Children in Placement review requirements please refer to the CAR Selection Process Guide, Revenue Maximization Unit. All Medicaid specific elements are explained in the Family Medicaid Reading Guide, Revenue Maximization Unit. Both are found in Appendix H – Administrative Review.

For Children in Placement, the following definitions are used in case reading:

Supervisor’s review findings will be as of the moment the case is read. Do NOT withhold supervisory review findings to give the MES an opportunity to make corrections. The accuracy rate is based on the findings as of the initial supervisory review. Corrections are made after the accuracy rate is determined.

Applications: Read for all affected months, beginning with the earliest of the prior months (if any) through the ongoing benefit month.

Annual Reviews: Read only the month of the review for all data elements required for the COA. Errors which occurred in months other than the month read will be counted incorrect only if the error affects the month being read for the review/special.

Specials: A “Special” is any case action taken other than application, annual review or denial. Read the entire case. However, only consider elements in error that were the result of the action taken by the current worker when calculating the accuracy rate of the case. All errors must be corrected.

Denials: Read all screens applicable to the denial and the reason for the denial. This includes at a minimum: Case Record, NARR, ADDR, STAT, AREP, and Notice Requirements.

Refer to the instructions accompanying Form 965 and Form 974 for specifics on how to complete. It is important to strictly adhere to the guidelines to ensure statewide standards and fairness.

ABD reviews should be completed using the ABD online review site. While the supervisor may review a case using the Form 974, Supervisory Review Summary Sheet, and keep a copy in a central file, it is not necessary to submit a copy to the State Office. Findings on each case reviewed should be reported via the ABD Medicaid Supervisory Review Database. These results are automatically reported to the State Office Data Analysis and Reporting section, which completes monthly reports on a county, regional and state level.