MES Certification Navigator
PI

Program Integrity

PI systems monitor for waste, fraud, and abuse, to ensure Medicaid funds are distributed properly and accurately.

CMS-Required Outcomes (18)

RefOutcomeSources
CP2
Validation
The system performs comprehensive validation of claims and claims adjustments, including validity of services.
42 CFR 431.05242 CFR 431.05542 CFR 447.2642 CFR 447.45(f)45 CFR 162.1002SMD Letter 10-017SMM Part 11 Section 11300
FM5The system accurately tallies recoupments by tracking repayments and amounts outstanding for individual transactions and in aggregate for a provider.
42 CFR 447
PBM9The system supports the identification of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, or prescribing or billing practices indicating abuse or excessive utilization among physicians, pharmacists and individuals receiving benefits by enabling the collection of pharmacy data to be used in retrospective drug utilization reviews.
42 CFR 456.703Section 1927 (g) of the SSA
PI1System can check member record to ensure the member on the claim was enrolled in the Medicaid program and the benefit was covered at the time of service. Membership enrollment records the system is checking against are updated daily. *Applicable to CP
PI2System provides a method for identifying suspected inappropriate services and incorrect billing. *Applicable to CP, E&E, MM
PI3System can verify with beneficiaries whether services billed by providers were received.
PI4System can suspend Medicaid payments in whole or in part to providers for whom the agency has determined there is a credible allegation of fraud and is conducting an investigation and other activities, including provide notice of suspension; referrals to MFCU; and documentation and record retention.
PI5System can perform provider lock-in for identified members responsible for fraudulent activity, or that have utilized services in excess of what is medically necessary (as defined by state guidelines), and can send notice to the impacted member and the appropriate provider. *Applicable to PM
PI6System can recover improper payments by: (a) Tracking repayments and outstanding amounts due at an individual transaction level as well as aggregating by provider, time period (b) Supporting electronic transfer back to the state (c ) Temporarily limiting future payments to provider(s) who have an outstanding recovery balance.
PI7System can complete the required independent certified audit of Disproportionate Share Hospital (DSH) payments for each Medicaid State Plan rate year using payment and utilization information.
PI8System can reject claims for items or services that were ordered or referred that do not contain a National Provider Identifier. *Applicable to CP
PI9System can support activities conducted by Medicaid RACs can including review all claims submitted by providers of items or services for which payment has been made to identify underpayments and overpayments and recoup overpayments as necessary.
PI10System can refer all cases of suspected provider fraud to the state's Medicaid Fraud Unit and provide access to Case Tracking as applicable.
PI11System can sample and review active cases, including negative cases, to determine eligibility errors in accordance with the state's MEQC pilot planning document.
PI12System can submit following information to CMS for among other purposes, estimating improper payments in Medicaid and CHIP, that include, but are not limited to— (1) Adjudicated fee-for-service or managed care claims information, or both, on a quarterly basis, from the review year; (2) Upon request from CMS, provider contact information that has been verified by the state as current; (3) All medical, eligibility, and other related policies in effect, and any quarterly policy updates; (4) Current managed care contracts, rate information, and any quarterly updates applicable to the review year; (5) Data processing systems manuals; (6) Repricing information for claims that are determined during the review to have been improperly paid; (7) Information on claims that were selected as part of the sample, but changed in substance after selection, for example, successful provider appeals; (8) Adjustments made within 60 days of the adjudication dates for the original claims or line items, with sufficient information to indicate the nature of the adjustments and to match the adjustments to the original claims or line items; (9) Case documentation to support the eligibility review, as requested by CMS; (10) A corrective action plan for purposes of reducing erroneous payments in FFS, managed care, and eligibility; and (11) Other information that the Secretary determines is necessary for these purposes.
PM11
Risk Level Assignment
A state user can assign and screen all applications by a risk categorization of limited, moderate, or high for a provider at the time of new application, re-enrollment, or re-validation of enrollment. A state user can adjust a provider's risk level due to payment suspension or moratorium.
42 CFR 455.450
PM17
Fraud
A state user can report required information about fraud and abuse to the appropriate officials.
42 CFR 455.17
PM18
Payment Suspension
The system, or a state user, can suspend payment to providers in cases of fraud.
42 CFR 455.23