Prepayment Claims Review Services
The purpose of this RFP is to procure a Contractor to conduct manual prepayment claims review of selected Medicaid Providers that have demonstrated significant abusive or aberrant billing problems. These problems are based on clinical decisions made as to the medical appropriateness and duration and intensity of services provided, as well as administrative decisions made where inadequate and/or improper documentation of services fails to substantiate the necessity of services billed.
Improper payments to such Providers represent misspent federal funds, which if not precluded result in the liability of the State for repayment of the federal share amount. This prepayment review shall be conducted consistent with federal requirements for a statewide surveillance and utilization control program that safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments as noted in 42 CFR, parts 455 and 456.
