42 C.F.R. §§ 431.830–431.836

§431.830. Basic elements of the Medicaid quality control (MQC) claims processing assessment system.

42 C.F.R. § 431.830

An agency must—

(a)

Operate the MQC claims processing assessment system in accordance with the policies, sampling methodology, review procedures, reporting forms, requirements, and other instructions established by CMS.

(b)

Identify deficiencies in the claims processing operations.

(c)

Measure cost of deficiencies;

(d)

Provide data to determine appropriate corrective action;

(e)

Provide an assessment of the State's claims processing or that of its fiscal agent;

(f)

Provide for a claim-by-claim review where justifiable by data; and

(g)

Produce an audit trail that can be reviewed by CMS or an outside auditor.

Notes, amendments, and revision history

Source

Source: Sections 431.830 through 431.836 appear at 55 FR 22170, May 31, 1990, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45188, Sept. 29, 1978, unless otherwise noted.

§431.832. Reporting requirements for claims processing assessment systems.

42 C.F.R. § 431.832

(a)

The agency must submit reports and data specified in paragraph (b) of this section to CMS, in the form and at the time specified by CMS.

(b)

Except when CMS authorizes less stringent reporting, States must submit:

(1)

A monthly report on claims processing reviews sampled and or claims processing reviews completed during the month;

(2)

A summary report on findings for all reviews in the 6-month sample to be submitted by the end of the 3rd month following the scheduled completion of reviews for that 6 month period; and

(3)

Other data and reports as required by CMS.

Notes, amendments, and revision history

Source

Source: Sections 431.830 through 431.836 appear at 55 FR 22170, May 31, 1990, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45188, Sept. 29, 1978, unless otherwise noted.

§431.834. Access to records: Claims processing assessment systems.

42 C.F.R. § 431.834

The agency, upon written request, must provide HHS staff with access to all records pertaining to its MQC claims processing assessment system reviews to which the State has access, including information available under part 435, subpart J, of this chapter.

Notes, amendments, and revision history

Source

Source: Sections 431.830 through 431.836 appear at 55 FR 22170, May 31, 1990, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45188, Sept. 29, 1978, unless otherwise noted.

§431.836. Corrective action under the MQC claims processing assessment system.

42 C.F.R. § 431.836

The agency must—

(a)

Take action to correct those errors identified through the claims processing assessment system review and, if cost effective, to recover those funds erroneously spent;

(b)

Take administrative action to prevent and reduce the incidence of those errors; and

(c)

By August 31 of each year, submit to CMS a report of its error analysis and a corrective action plan on the reviews conducted since the cut-off-date of the previous corrective action plan.

Notes, amendments, and revision history

Source

Source: Sections 431.830 through 431.836 appear at 55 FR 22170, May 31, 1990, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45188, Sept. 29, 1978, unless otherwise noted.

42 C.F.R. §§ 431.830–431.836

§431.830. Basic elements of the Medicaid quality control (MQC) claims processing assessment system.

Source

Authority

Source

§431.832. Reporting requirements for claims processing assessment systems.

Source

Authority

Source

§431.834. Access to records: Claims processing assessment systems.

Source

Authority

Source

§431.836. Corrective action under the MQC claims processing assessment system.

Source

Authority

Source

Cite this provision

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