Clinical Compliance Monitoring
The Clinical Compliance Monitoring Unit is comprised of a multi-disciplinary team of clinical staff, including Behavioral Health Clinicians, Pharmacists, Nurses, and Analysts working together to address clinical care areas of oversight with one focus and goal: to ensure access to quality care in the Medicaid Managed Care environment. The unit has specific expertise in both how the managed care system operates and general health/behavioral health system of care operations, as well as the delivery of services to the Medicaid population. The unit’s functions are as follows:
- Provide clinical reviews of Statewide Medicaid Managed Care (SMMC) plan programs and initiatives.
- Perform targeted monitoring of SMMC and Dental contract services to ensure that Medicaid enrollees receive services provided in the quantity and quality required for treatment of the enrollee’s condition, in compliance with the SMMC contract.
- Review and analyze data submitted by the SMMC and Dental plans for the following reports:
- Conduct quality reviews of the following Medicaid programs:
- Participate in interagency child staffing meetings for medical neglect, behavioral health services, and the Children’s Multidisciplinary Assessment Team (CMAT).
- Adverse and Critical Incident Summary Report
- Case Management File Audit Report
- Case Manager and Provider Training Report
- Case Manger Caseload Report
- Child Staffing Attendance Report
- Critical Incident Individual Report
- Denial, Reduction, Termination or Suspension of Services Report
- Electronic Visit Verification Report
- Enhanced Care Coordination Report
- Enrollee Roster and Facility Residence Report
- ER Visits for Enrollees without PCP/PDP Appointment Report
- Health Risk Assessment Report
- Hernandez Settlement Agreement Log - MMA
- Hernandez Settlement Agreement Survey - MMA
- Inter-Rater Reliability Audit
- Medical Foster Care Services Report
- Missed Services Report
- Oral Health Risk Assessment Report
- Participant Direction (PDO) Roster Report
- PCP/PDP Appointment Report
- Provider Network and Qualifications Report
- Residential Psychiatric Treatment Report
- Service Authorization Performance Outcome Report
- Subcontractor Audit Report
- Person-Centered Monitoring (Performance Measures Case File Review)
- Complaint Administration Unit Report
- Early Intervention Services
- Familial Dysautonomia Waiver
- Global Transplant
- Housing Pilot Waiver
- Medicaid Certified School Match Program
- Medical Foster Care Program
- Model Waiver
- Pharmacy Reports
- Prior Authorizations
- School District Administrative Claiming
