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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 46 - Section 11. Program Integrity (Section 2101(a)) □ Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan, and continue to Section 12. 11.1  The State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42 CFR 457.940(b)) 11.2 The State assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42 CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1  42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2  Section 1124 (relating to disclosure of ownership and related information) 11.2.3  Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4  Section 1128A (relating to civil monetary penalties) 11.2.5  Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6  Section 1128E (relating to the National health care fraud and abuse data collection program) 11.3 Fraud and Abuse Response: The delivery systems described below apply to MO HealthNet, SCHIP 1 and SCHIP 2. MO HealthNet Fee-For-Service Delivery System Fraud and Abuse Detection System (FADS) -- Thomson Medstat’s Advantage Suite® for Fraud Detection is a comprehensive, multi-functional solution for identification and investigation of fraud, waste, and abuse. It provides financial, utilization, eligibility, and quality of care reporting capabilities; in addition, it provides rules-based capabilities for detecting and investigating potential fraud, abuse and waste. The system detects known patterns of aberrant behavior and can automatically “alert” the user when such a pattern is detected. It provides drill-down paths and ad hoc inquiry capabilities to support data investigation at the