Must utilize a minimal level of manual effort in providing IV.N.5 Operations Phase - information that reveals potential Business Architecture defects in level of care and quality Overview - Program Integrity of service. IV.N.5 Operations Phase - Must suppress processing on an Business Architecture individual(s) within specified Overview - Program Integrity categories on a run-to-run basis. Must support pattern recognition and provide an automated fraud and abuse profiling system for the ongoing monitoring of provider and IV.N.5 Operations Phase - member claims to detect patterns Business Architecture of potential fraud, waste, abuse Overview - Program Integrity and excessive billing. Must update all reference data IV.N.5 Operations Phase - based on a schedule agreed upon Business Architecture with State.(e.g. claims, provider, Overview - Program Integrity member) Must maintain a process to apply IV.N.5 Operations Phase - weighting and ranking of those Business Architecture exception report items identified by Overview - Program Integrity the State. Must exempt individual and mass IV.N.5 Operations Phase - adjustments or voids from SURS Business Architecture profiles and reports based on Overview - Program Integrity configurable rules. IV.N.5 Operations Phase - Must recommend members for Business Architecture referral to restricted access Overview - Program Integrity programs. Must perform “absence of” scenario analysis (examples include inpatient hospitalizations or IV.N.5 Operations Phase - prescriptions with no physician Business Architecture visit, durable medical equipment Overview - Program Integrity with no relevant diagnosis).
IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must utilize a minimal level of manual effort in providing information that reveals potential defects in level of care and quality of service. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must suppress processing on an individual(s) within specified categories on a run-to-run basis. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must support pattern recognition and provide an automated fraud and abuse profiling system for the ongoing monitoring of provider and member claims to detect patterns of potential fraud, waste, abuse and excessive billing. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must update all reference data based on a schedule agreed upon with State.(e.g. claims, provider, member) IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must maintain a process to apply weighting and ranking of those exception report items identified by the State. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must exempt individual and mass adjustments or voids from SURS profiles and reports based on configurable rules. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must recommend members for referral to restricted access programs. IV.N.5 Operations Phase - Business Architecture Overview - Program Integrity Must perform “absence of” scenario analysis (examples include inpatient hospitalizations or prescriptions with no physician visit, durable medical equipment with no relevant diagnosis).
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