Abstract: . . .  Medicaid Compliance Audit that includes waiver services. Auditors review Medicaid billed events per a sample of individual directly enrolled providers. This review includes monitoring of requirements that address staff qualifications, service authorizations, service plans, service documentation, and billing protocol. In addition, the Behavioral Health Unit of DMA conducts quality assurance reviews monthly that include a review of the application of eligibility criteria for individuals participating in the waiver. Each month DMA selects a random sample of waiver cases that were active on the last day of the review month. Reviews occur either on site or the records are sent to DMA for a desktop r . . .
. . .  service for urgent and routine needs, the percent determined to need emergent, urgent and routine care and of those, the percent for which care is initiated within the required timeframes. DHHS reviews a random sample of up to 20 urgent services annually to verify accuracy of the information. The proposed waiver provides for initial Level of Care reviews to occur at the Local Management Entity level as part of the Utilization Review and Authorization process. Utilization Review and Authorization of services is provided by a Qualified Developmental Disability Professional trained and competent to approve Plans of Care. Quarterly monitoring of the local approval or authorization process is provided by the Program Accountability Team. Annually the . . .
. . .  Program Accountability Team. Annually the Program Accountability Team and DMA’s Behavioral Health Unit conduct a Medicaid Compliance Audit that includes waiver services. Auditors review Medicaid billed events per a sample of individual directly enrolled providers. This review includes monitoring of requirements that address staff qualifications, service authorizations, service plans, service documentation, and billing protocol. In addition, the Behavioral Health Unit of DMA conducts quality assurance reviews monthly that include a review of the application of eligibility criteria for individuals participating in the waiver. Each month DMA selects a random sample of waiver cases that were active on the last day of the review month. Reviews occur either . . .
. . .  birth month of the individual. This activity is an integral part of Targeted Case Management required activities, which are the responsibility of a Qualified Professional. Pending recommendations of level of care, the LME will complete the final determination for continued authorization of Level of Care and Medical Necessity. Page 22 NC DMH/DD/SAS Quality Management Plan – 1915 (c) Waiver 17 Discovery The LME reports quarterly the number of persons requesting service for urgent and routine needs, the percent determined to need emergent, urgent and routine care and of those, the percent for which care is initiated within the required timeframes. DHHS reviews a random sample of up to 20 urgent services annually to verify accuracy of the information. . . .
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