N.J. Admin. Code § 8:85-1.12

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:85-1.12 - Clinical audit and MDS verification

(a) Clinical audit is a method of utilization control under the enforcement authority of Section 1902(a)(30)(A) of the Social Security Act, to monitor the continued utilization of and payment for NF care and services reimbursable under the Medicaid program. Clinical audit has as its major component verification of NF services provision.

(b) In order to validate that the direct care component of the rate is supported by medical record documentation and accurately coded and submitted, the Department shall conduct a periodic MDS verification review, which shall:

1. Compare the MDS assessment coding with the corresponding medical record documentation to determine unsupported MDS assessments;

2. Determine the completeness and accuracy of the residents and MDS assessments identified on the resident roster; and

3. Determine the accuracy of the resident payment source listed on the resident roster.

(c) Professional staff designated by the Department shall periodically conduct a post payment review of New Jersey Medicaid beneficiaries for whom NF services have been provided. The review shall principally involve assessment of the Medicaid beneficiary's care needs and evaluation of treatment outcomes, based on direct observation of the beneficiary and examination of clinical and related records. The focus of the review shall be on the following areas:

1. Comparative analysis of a beneficiary's identified care needs to NF claim reports;

2. Appropriate utilization and provision of required services; and

3. Effectiveness and quality of provided services.

(d) Enforcement action will be taken by the Department as follows:

1. As a result of the clinical audits and MDS verifications, aberrations in the reporting and/or provision of services and failure to comply with the requirements of this chapter shall be documented and reported to the NF for corrective action.

2. A pattern of practice of significant proportion wherein the NF has provided items or services at a frequency or amount determined unnecessary, or of a quality that does not meet the standards outlined in this chapter, will result in an increase, reduction or termination of services, and ultimate restriction of the NF participation in the Medicaid Program.

3. Findings from a clinical audit or an MDS verification shall be used to reduce an NF's per diem payment rate to reflect the audited costs, days, case mix index or other variables used in the rate setting process.

N.J. Admin. Code § 8:85-1.12

Recodified from N.J.A.C. 10:63-1.12 and amended by R.2005 d.389, effective 1/17/2006.
See: 36 N.J.R. 4700(a), 37 N.J.R. 1185(a), 38 N.J.R. 674(a).
Rewrote introductory paragraph (b) and (b)1; in introductory paragraph (c), substituted "Department" for "Division".
Amended by R.2011 d.121, effective 4/18/2011.
See: 42 N.J.R. 1793(a), 43 N.J.R. 961(c).
Section was "Clinical audit". Added new (b); recodified former (b) and (c) as (c) and (d); in (d)1, inserted "and MDS verifications"; and added (d)3.