1. (a) The purpose of a surveillance and utilization review and control program is for the department to:

   1. (1) Assess the quality of the care, services, and supplies received by recipients and for which a medicaid program has reimbursed providers;
   2. (2) Detect, correct, and prevent occurrences of unnecessary or inappropriate medical care, service, or supply usage by recipients, or provision by providers, for which a medicaid program has reimbursed providers; and
   3. (3) Ensure that accurate and proper reimbursement has been made for the care, services, or supplies provided.

2. (b) The department or managed care organization (MCO) shall be responsible for surveillance and utilization review and control activities by:

   1. (1) Performing the utilization reviews directly, or contracting with professional organizations for the performance of reviews; and
   2. (2) Monitoring the results of reviews to ensure appropriate corrective action has been taken.

3. (c) Reviews described in (b)(1) and (2) above shall include:

   1. (1) Reviewing recipient utilization and provider service profiles in accordance with 42 CFR 456.23;
   2. (2) Reviewing provider claims selected randomly;
   3. (3) Reviewing claims for all or selected services for a given period of time;

   4. (4) Application of the Centers for Medicare and Medicaid Services’ National Correct Coding Initiative (CMS NCCI) to review claims processed by the fiscal agent or MCO to ensure:

      1. a. That the provider has coded claims properly; and
      2. b. That the claims processing system has made proper payment through application of edits based upon the CMS NCCI;
   5. (5) An on-site review of hospital, office, or other provider records to establish the accuracy of claims data and to ensure other documentation supports the claim for services rendered;
   6. (6) Contacting recipients to verify that services or supplies claimed for reimbursement by providers were actually rendered;
   7. (7) Contacting providers to recover overpayments or correct underpayments; and
   8. (8) Referring cases of potential fraud for further investigation and possible criminal action, pursuant to 42 CFR 455.15.

Source. (See Revision Note at chapter heading He-W 500); ss by #6574, eff 9-12-97; ss by #6925, eff 1-1-99; ss and moved by #8781, eff 1-1-07 (from He-W 520.06); ss by #9365, eff 1-17-09; ss by #12188, eff 5-25-17; ss by 14415, eff 10-22-25, EXPIRES 10-22-35