Illinois Medicaid Recovery Audit Contract RAC Overview February - - PowerPoint PPT Presentation
Illinois Medicaid Recovery Audit Contract RAC Overview February 2017 Provide information Introduction to HMS Illinois Medicaid RAC Program Share Details on HMS Review Process Webinar Goals Scenario Methodology
RAC Overview
February 2017
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Lara Wright Megless, HMS Regional Director
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healthcare system so that healthcare dollars can benefit more people.
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demonstration project to identify Medicare
expanded RAC to Medicaid.
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Identify improper payments through analysis of paid Medicaid Claims. Deliver results grounded in quality, integrity and accuracy to policy. Partner with the Single State Agency to ensure a fair and consistent process. Ensure clear, concise, and timely communication with providers. Afford all providers their rights to appeal.
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HFS Policy Review Claims Data Mining
(Based on PData olicy Guidelines)
Improper Payment Scenario Approval from HFS Edits and Analytics, and Clinical Claim Review Potential Improper Payments Identified and Letters Mailed Provider Reconsideration/ Appeals and Offset Scenario Analysis, System Remediation, and Provider Education
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Claim Edits and Analytics are applied in scenarios where improper payments can be identified clearly and unambiguously.
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Clinical Claim Review is required when analysis identifies a potential improper payment that cannot be automatically validated
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to HMS no later than 30 calendar days from the date the records request letter is received.
is issued: Submit reconsideration records and documentation to HMS no later than 30 days from the date the Preliminary Findings letter is received, if applicable.
letter is issued: Submit Reconsideration documentation, if applicable, to HMS no later than 30 days from the date the Preliminary Findings letter is received.
has been finalized and the provider has had an opportunity to submit reconsideration documentation or appeal. Do not make payment adjustments. Recoupment will occur either by payment withhold or cashier’s or certified check.
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Edits and Analytics Clinical Claim Review
Agree – No further action is necessary at this time. Do not make payment adjustments. 30 Days to submit medical records (fax or mail paper, or mail CD/DVD) Disagree – 30 Days to submit Reconsideration documentation in response to Preliminary Findings Letter 60 Days for HMS to review and notify via Preliminary Findings Letter Continued disagreement after receipt
days to submit appeal request to State of IL Disagree – 30 Days to Reconsideration documentation in response to Preliminary Findings Letter Agree – submit Payment Agreement to HMS, claims will be submitted to HFS for offset on future remittance or repayment by Cashier’s or Certified
adjustments. Continued disagreement after receipt
to submit appeal request to State of IL
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Setting
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http://hms.com/us/il-providers/home/
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1(855) 699-6292
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