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Missouri Application for the State Children’s Health Insurance Program Effective Date: 09/01/2007 Approval Date: 09/28/2007

Prior Approval Date: - 47 - provider, recipient, and detailed claim level. The Advantage Suite database provides users with access to integrated MO HealthNet Division paid and denied healthcare claims, managed care encounter records, provider enrollment information, eligibility data, financial records, and other detail-level data. If the review findings question the provider’s license or certification, an appropriate referral is made to the Missouri Division of Professional Registration. If the review findings question the practitioner’s Bureau of Narcotic and Dangerous Drugs (BNDD) prescribing privileges, the appropriate referral is made to BNDD. If a question of potential fraud exists, the case is referred to the Office of Attorney General/MO HealthNet Fraud Control Unit (OAG/MFCU). Missouri Statute allows for the MO HealthNet provider’s appeal of the result of the MO HealthNet Division's post payment reviews. If the provider is adversely affected by the MO HealthNet Division's decision, he/she may appeal the decision to the Administrative Hearing Commission. Missouri Medicaid Audit and Compliance (MMAC) Unit is the agency within the Missouri DSS that is responsible for referring all cases of suspected provider fraud to the OAG/MFCU. The Missouri DSS has a Memorandum of Understanding (MOU) with OAG/MFCU. One of the requirements of the MOU is to conduct monthly meetings to exchange information and discuss potential cases. Evaluation criteria are based on the specific requirements stated in each program’s MO HealthNet Manual and updated by MO HealthNet Bulletins. All programs are evaluated for adequate documentation. The MMAC Unit conducts post payment reviews of MO HealthNet providers to determine the propriety of claims reimbursed by MO HealthNet and monitors the utilization of MO HealthNet services in the State. Following a preliminary review, if the reviewer is suspicious of fraud the case must be referred to the OAG/MFCU. Suspicion of fraud can be determined by unexplained or unreasonable billing patterns. In a preliminary review by Program Integrity staff the reviewer is comparing the claim data to the provider’s treatment records. Suspicion of fraud can be repeated findings of lack of documentation (false claims), up coding (billing higher level codes than what is documented), and/or inadequate documentation. MO HealthNet providers are selected to be reviewed from either referral, exception reports, and/or other system generated reports. Referrals concerning possible misutilization may be received from providers, recipients, consultants,