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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 - 48 - employees of the MO HealthNet Division, as well as staff from other agencies. Exception reports are produced on providers that have exceptional patterns of utilization, or that deviate from established norms. Medstat/Advantage Suite leads are on providers and recipients who have a suspected pattern of waste or abuse. A review of MO HealthNet claims reimbursed is performed on each of the selected providers or project in order to determine program compliance. This review is completed by either desk review or field review. The appropriateness and quality of service are also considered for the claims being reviewed. If a question regarding the quality of service, medical necessity or medical interpretation exists, the case is referred to the Division’s State Consultant(s) for review. The final outcome of a provider review may include one or more of the following administrative actions: determination of overpayment, withholding of payments, transfer to closed-end agreement, provider education, prepayment review, referral to another state agency, or suspension or termination of the provider’s MO HealthNet participation agreement. If an overpayment is identified, a certified mailing is sent to the provider outlining all errors noted in the review and informing the provider of the total amount overpaid. The provider is also notified of any repayment options available to them. The MMAC Unit monitors MO HealthNet recipient utilization of services. The MMAC Unit uses several resources including, but not limited to, the Fraud and Abuse Detection System and referrals, to detect MO HealthNet recipient aberrant utilization patterns. Recipients with a pattern of suspected abuse are reviewed by Program Integrity staff to determine if there is legitimate cause for the excessive utilization or if there is suspicion of possible abuse of the MO HealthNet Program. Based on the outcome of the analysis, the recipient is educated regarding the appropriate use of MO HealthNet services or, if warranted, the recipient is placed on Lock–In status if the utilization pattern is not supported by a medical need. The recipient can be locked-in to a pharmacy or to a physician or to both based on the aberrant behavior. Suspicion of recipient fraud, such as MO HealthNet identification card sharing and false income reporting, is referred to the MO HealthNet Investigation Unit within the DSS for further investigation and referral to law enforcement. MO HealthNet Managed Care Delivery System In accordance with Missouri Statute, MO HealthNet Managed Care contract requirements, and policy statements regarding fraud and abuse, the MCOs must perform fraud and abuse prevention, coordination, detection, investigation, and enforcement