Current through Register Vol. 47, No. 5, March 10, 2024
.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.
8.090.2
METHOD
.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.
