AGENCY: Department of Health and Human Services. Healthcare Administration. Division of Integrated Healthcare. Office of Eligibility Policy
SERIES: 8058
TITLE: Terminated restricted client case files
DATES: 1982-
ARRANGEMENT: None
DESCRIPTION: This is a record of medicaid clients who have abused their privileges and have been restricted to using only one doctor and one pharmacy. It includes Medicaid Management Information Systems (MMIS) Surveillance and Utilization review (SUR) Exception Profile Report, MMIS SUR Exception Log, MMIS Medicaid Program Claim History Detail Report, a case summary, a restriction letter to the client, a letter from the client specifying who will be his/her doctor and pharmacist, a letter to the doctor and to the pharmacist advising them of the client's restriction, and a termination letter. The information includes: A) MMIS SUR Exception Profile Report: gives the date of the report; the recipient's name, identification number, the county of residence; the type of aid the client is receiving; the client's age, sex, and race; the type of health care provisions the client is receiving; the eligibility dates; and a breakdown of a pattern of services used for the four previous quarters, including the type of services and the amount of charges per quarter and a notation as to which services used constituted an exception to the average of client services. B) MMIS SUR Exception Log: gives the date of the report and a list of recipients who had unusually high medicaid claims including the recipient's identification number and name, and the client's age, sex, race, and the type of aid received. C) MMIS Medicaid Program Claim History Detail Report: gives a breakdown of the medicaid claims submitted by the client including the report date, the recipient's name and identification number, the recipient's sex, age, aid category and level of care category, and all the claims filed by the client giving the health care provider's identification number and name, the type of claim, the amount charged for the care, and the amounts paid by medicaid and by third parties, the claim control number, the adjustment date, the claim date, the dates of service, if the patient hospitalized, the dates admitted and discharged, a breakdown of the specific services provided (emergency room, pharmacy, etc.), and the amount of charges submitted per service and the amount of the allowed charge. D) Case summary: gives a history of all actions on the case with the date of the action and a description of the action taken. Also includes a summary of the claims information.
RETENTION
Retain for 3 year(s)
DISPOSITION
Destroy.
RETENTION AND DISPOSITION AUTHORIZATION
These records are in Archives' permanent custody.
APPROVED: 08/1986
FORMAT MANAGEMENT
Paper: Retain in Office for 1 year and then transfer to State Records Center. Retain in State Records Center for 2 years and then destroy.
APPRAISAL
Administrative
Once the client has been taken off restrictions, this record should be kept for three years to see if the client again begins to abuse his/her medicaid privileges. A record of previous problems may have a bearing on later decisions as to how to deal with the client.
PRIMARY DESIGNATION
Private