10 Colo. Code Regs. § 2505-10-8.091

Current through Register Vol. 47, No. 20, October 25, 2024

Section 10 CCR 2505-10-8.091 - PURPOSE

.10 Medicaid Quality Control is a unit within the Medical Assistance Division of the Colorado Department of Social Services. This unit is independent of and functionally different (as described below) from the Quality Control Unit described in Colorado State Department of Social Services Staff Manual 3 Section 3.870.11 et seq.

.11 Medicaid Quality Control is a federally required ongoing review conducted by the Division of Medical Assistance to determine the extent to which third party liability or claims processed by the fiscal agent contain errors.

.12 The Medicaid Quality Control system is a method of State administration that is intended to reduce the incidence of claims processing and third party liability errors. This is accomplished by means of three processes.

A. A continuous review of the Medicaid claims processed for a statistically reliable statewide sample of cases;

B. The periodic assembly and analysis of findings to determine the incidence of errors; and

C. The taking of corrective action to reduce the level of error, and, if necessary, bring such error rate within established tolerance.

8.090.2METHOD

.20 The Medicaid Quality Control Review covers:

A. The manner in which county departments identified and then documented recipient's third party medical insurance benefits and coverage;

B. Accuracy of information provided by client;

C. Accuracy of fiscal agent action with respect to claims processing and third party liability for paid claims.

D. Medically necessary transportation authorized by the State or county departments.

E. Medical certification for recipients in long term care facilities.

.21 Errors are of two types:

A. Third party liability errors- when there is a third party(ies) which is available to pay for medical services for eligible recipients, but the party(ies) was not known or fully utilized prior to claims payments.

B. Claims processing errors- when claims were paid which did not contain all necessary information, which did not meet the service or payment amount restrictions, or which did not reflect liability for payment correctly.

.22 Third party liability errors are reported to the county departments by the Quality Control Unit via the Third Party Recovery Unit, Division of Medical Assistance, Colorado State Department of Social Services with requests for the county's report of corrective action.

.23 Claims processing errors are reported to the appropriate section within the Medical Assistance Division and/or fiscal agent with requests for corrective action.

.24 At periodic intervals, the findings of Medicaid Quality Control are assembled, tabulated, and summarized for use by the State Department of Social Services to meet federal reporting requirements.

10 CCR 2505-10-8.091