Case Accuracy Review Selection Process: Revenue Maximization Unit | Medicaid
Overview
Case accuracy reviews are an essential tool used to ensure all mandated case accuracy standards are met. Full reviews from initial determination through review month in each Medicaid Class of Assistance are necessary so that not only error prone areas but all areas will be looked at for accuracy. The CASE ACCURACY REVIEW (CAR) form and instructions have been developed to review all OFI programs (excluding ABD) for case accuracy. The new case accuracy review form will enable supervisors and others to identify strengths and error prone areas. Automation of the Case Accuracy Review Form will enable supervisors and others to monitor the strengths and training needs of not only the state, but also individual counties and workers. The following guidelines are established for case accuracy reviews:
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First level reviews will be completed monthly for Children in Placement Medicaid in all counties/regions.
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The Rev Max Quality Assurance Unit will perform second level reviews during regional visits.
Random Sampling Methods Overview
The number of reviews completed must be random and will be based on the following:
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A minimum of 5 cases per Rev Max Specialist with a maximum of 25 cases per supervisor for all COA’s to be reviewed each month.
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Regions are also encouraged to read cases in error prone areas such as earned income and unearned income cases.
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If additional cases need to be read, supervisors should select samples from active and closed cases within the review month.
Sampling Method by Program
Medicaid:
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Deficiencies are now possible in Family Medicaid
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If additional reviews are to be pulled, supervisors should select samples from recently closed cases, using the case manager’s monthly work cards or cases identified through other methods
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At least quarterly, cases from all Medicaid COAs must be reviewed
First Level Reviews
The number of reviews can be adjusted to accommodate the demographics of a region’s caseload. Any adjustments would need to be approved by the Rev Max Director.
Second Level Reviews
Second level reviews are completed by Quality Assurance unit members. This review is required to ensure first level reviews are completed in accordance with all program policy and CAR procedures. The sample size for second level reviews will be 100% of the total IV-E cases read per region.
Document Completion
The CAR form is designed to improve the process of case reading for Title IV-E and Medicaid programs. Completion of a form for each case reviewed is mandatory. The original review form will be maintained in the case record and the summary sheet will be filed with the supervisor’s monthly CAR file for reporting purposes. In addition, the reviewer will document each case reviewed on the CAR form with the following information:
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The date the review was completed
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The findings, noted as correct, error or deficiencies
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If the case is incorrect, the error/deficiency must be documented with correction(s) needed and the due date for correction(s) to be made
It is vital regions track noted errors and deficiencies to ensure all required corrections are completed. A reasonable timeframe for completion of necessary corrections is to be established and adhered to for all programs. Quality Assurance Unit members will review each error/deficient case for corrective action accuracy.
Definitions
Where appropriate the following definitions will be used:
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Accuracy Rate
#Cases Initially Correct + #Cases Initially Deficient / #Cases Read
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Correct Case
Medicaid eligibility, COA, funding source and reimbursability are correctly determined and thoroughly documented in case record and at all appropriate screens in Gateway and SHINES.
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Deficient Case
Initial determination, review item or notice of change insufficiently addressed in case record and/or SHINES/Gateway documentation and there is no error in the eligibility and reimbursability determination.
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Error Case
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Incorrect eligibility/COA and/or reimbursability determination, OR
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Eligible for and not receiving benefits, OR
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Incorrect AFDC Relatedness criteria determination: financial need, deprivation, specified relative, living with/removal from, age, OR
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Ineligible for but receiving benefits, OR
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Denial or closure of a case that was actual eligible
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Reporting
Reports of accuracy findings are due by the fifteenth of the month following the review month. Regions must report all case reviews completed, including errors discovered prior to finalization.
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Reports are due by the 15th of each month; if the 15th falls on a weekend or a holiday, the report is due the following workday. Revisions are not possible after the deadline.
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One report per region should be submitted in a single e-mail as attachments with the region number in the subject line.
Request for Reduction
The minimum number of case accuracy reviews for all programs is required to be completed each month unless a reduction request is submitted and approved by the Rev Max Unit Manager.
No reduction will be approved for a prior month. The request must be approved by the Rev Max Director prior to the month of reduction request.
Regional Case Accuracy Review Plan
A case accuracy review plan will be developed by each region. The plan will be approved by the RevMax Unit Manager. The first plan is due to the RevMax Unit Manager prior to implementation of the new CAR process. The case accuracy review plan will include the following:
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The total number of case accuracy reviews with a percentage breakdown of each funding source being reviewed.
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A process for reading records when there are supervisor/worker vacancies or supervisors/workers out on extended leave.
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This plan should not utilize Field Program Specialists as a first option in completion of case reviews.
In summary, the case accuracy review is an important tool for supervisors to use to monitor not only the quality of work being done but also the building of stronger families. The full record in conjunction with SHINES reviews will ensure supervisors are looking at the quality of the case and compliance with Title IV-E statutory and regulatory provisions and application of Medicaid policy.