MEDICAID PROGRAM INTEGRITY MANUAL CHAPTER …

MEDICAID PROGRAM INTEGRITY MANUAL CHAPTER 1 MEDICAID INTEGRITY PROGRAM (MIP) Table of Contents (Rev. 10384, Issued: 10-09-20) Transmittals for CHAPTER 1 Basis of Authority Statutory/Regulatory Citation Background Definitions State Collaboration Purpose Complaint and Lead Screening Vetting Process Investigation Review Process + Initiation of an Investigation Release of MEDICAID Data to UPIC Extrapolation Look Back Period Medical Review for PROGRAM INTEGRITY Purposes Request of Medical Records Review of Medical Records Completion of a Medical Records Review Overpayment Assessment Documentation of Investigation and Medical Review Findings Overpayment Resolution Process Calculation of FFP Based on State s Date of Expenditure State Appeal Process Close-Out Letters MEDICAID Settlement Negotiations Requests for Information MEDICAID Payment Suspensions Prepayment Medical Review Revocations and Terminations Immediate Advisements Fraud Referrals Unified Case Management (UCM)

geographic areas or “jurisdictions” defined by individual Task Orders. The UPICs perform numerous functions to detect, prevent, and deter specific risks and broader vulnerabilities to the integrity of the Medicare and Medicaid programs including, but not limited to:

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