We audited managed care organizations (MCOs) to determine their compliance with selected legal and contract requirements to report patient encounter and medical claims data to the Department of Human Services. For the sample records that we tested, we concluded that six MCOs complied with these reporting requirements, and the payment information was accurate and complete. Two MCOs also generally complied with these requirements, although we found a small number of exceptions.
We concluded that the Department of Human Services and county agencies Generally Complied with eligibility requirements for the Medical Assistance population included in our audit scope. Among enrollees age 65 or older and enrollees who were blind or had a disability, DHS and county agencies determined eligibility accurately in most of the samples we tested. However, for a small percentage of enrollees, DHS eligibility policies were not followed, or the enrollee did not meet eligibility requirements.
Early Childhood Programs (Apr 26th)