Medical Audit. The Division shall conduct, at minimum, annual medical audits of the Contractor during which the Division will identify and collect management data including information on the use of services and enrollment and disenrollment policies to ensure that the Contractor furnishes quality and accessible health care to enrolled beneficiaries. The Division will review any of the Contractor's policies and procedures for compliance with the terms of this Contract and any policies and procedures for Plan Services. The Division shall also procure an annual external review with follow-up review of the quality, appropriateness and timeliness of health care services, provided by or on behalf of the Contractor, by an independent peer review organization under contract with the Division or a private accreditation body and the Contractor shall cooperate with the party conducting this review. This evaluation shall be based upon the documentation present in medical records, personal interviews, aggregate data, complaints, grievances or other data received from Enrollees or providers. The Division will investigate any suspected cases of fraud and abuse in the delivery of services.
Appears in 6 contracts
Samples: medicaid.ms.gov, www.medicaid.ms.gov, medicaid.ms.gov
