Haw. Code R. § 17-1741-3 - Surveillance and utilization review

To safeguard against unnecessary or inappropriate use of services under the medical assistance program, excess payments and to assess the quality of those services, the department shall:

(1) Conduct post payment reviews and audits of a statistically significant sampling of provider claims;

(2) Compare provider and recipient utilization of services to establish statistical models of average provider and recipient utilization patterns;

(3) Select for review those providers and recipients with exceptional utilization patterns; and

(4) Take necessary remedial measures and corrective action to ensure the effectiveness of the program.

Notes

Haw. Code R. § 17-1741-3

[Eff 08/01/94] (Auth: HRS § 346-14; 42 C.F.R. §§430.10, 431.10, 456.1) (Imp: 42 C.F.R. §§456.1, 456.3 - 456.6, 456.22, 456.23)