Quality Assurance/Utilization Review/Evaluation and Research

The program employs a system of prospective utilization review and retrospective quality assurance review to ensure the appropriateness of participants for enrollment and services for payment. The program's automated eligibility verification system provides pre-authorization to providers for covered services. System edits are programmed to prevent duplication of payment, unauthorized service and assure participant eligibility. The program utilizes the AIDS Institute Utilization Review agent from the Primary Care Medicaid Program for additional oversight of providers. The program conducts reviews of service utilization patterns to identify and address issues of inappropriate utilization or provider fraud. Data collected through the program is coordinated with other data sources as part of the ongoing AIDS Institute evaluation and research activities