agency for health care administration medicaid …order to maintain smooth work flow and accurate...

Attachment 1.2-8

AGENCY FOR HEALTH CARE ADMINISTRATIONMEDICAID OFFICE

Director ofMedicaid

PereonalSecretary

I

Sre HumanSarv. ProgramAdministrator

Eleven AreaOf fices

ProgramAnalysis

Third PartyLiability andContract Mgt.

ProgramDevelopment

Managed HealthCare

Amendment 93-39Effective 7/1/93Supersedes 89-10Approved 10/ 2 1 / 9 4

Revised Submission'JUl 2 2 1994

Attachment 1.2-B

ORGANIZATION AND FUNCTION OF THE MEDICAID OFFICE

Attachment 1.2-B, Page 1 shows the organizational chart of theMedicaid Office. The major functions of the four administrativeunits and the eleven area offices are discussed below. Alsolisted is the Program Integrity unit, which is under thesupervision the Inspector General for Health Care Administration.

Program AnalysisProvides the planning, research, evaluation, analysis andreporting capabilities required by the Medicaid program in thearea of cost reimbursement, fiscal and bUdget planning, dataanalysis and forecasting, and alternative health plans. Directsaudit programs.

Program Development

Develops, coordinates, implements and monitors Medicaid programpolicy so that compliance with state and federal laws is ensuredand that services are made available in the most cost effectivemanner; and administers the program's medical authorizationfunction. Plans and implements Medicaid provider and consumerrelation activities and exceptional claims resolution, andenrolls Medicaid non-institutional providers.

Managed Health Care

Plans, develops, implements and monitors managed care programs,including home and community based waivers and freedom of choicewaivers, prepaid health plans, and demonstration grant programs.Directs special projects.

Medicaid Third Party Liability and Contract Management

Plans, develops and implements third party liability policies andprocedures. Manages contract for fiscal agent services todevelop, operate and maintain the Florida Medicaid ManagementInformation System (FMMIS). Oversees Medicaid eligibilityprogram policies and procedures.

Area Medicaid Offices

The state is divided into eleven area Medicaid offices, which areunder the direct supervision of the Director for Medicaid. Thearea offices are the local liaison to Medicaid providers andlocal Department of Health and Rehabilitative Services staff.The area offices are responsible for claims resolution,institutional quality of care monitoring, program training andprogram reviews.

Amendment 93-39Effective 7/1/93Supersedes. 89-10Approval 10/21/94

Revised Submission 'JOe 2 2 1994

Attachment 1.2-B

Area offices have the following professional medical personneland supporting staff:

* Registered Nurse Specialist (30.5 positions): Plans,coordinates and directs activities for the medical reviewfunctions and requests for service authorizations relating toEPSDT services for children under 21 years of age.

* Clerk Typist specialist (3 positions): Provides typingassistance for Registered Nurse Specialists.

* Word processing systems operator: Provides word processingsupport for Registered Nurse specialists.

Office of Program Integrity (Under supervision of the Agency forHealth Care Administration's Inspector General's office)

Administers Medicaid utilization control and fraud and abuseinvestigative functions and monitors various quality of carerequirements. This includes ensuring that appropriate servicesare furnished, detecting and investigating possible fraud andabuse; determining overpayments to providers and recoupinginappropriate payments; educating providers concerning MedicaidpOlicy; coordinating administrative sanctions and referringproviders (when appropriate) to the Medicaid Fraud Control Unitin the Office of the Auditor General for criminal investigation.

Program Integrity has the following professional medicalpersonnel:

* pharmaceutical Program Manager: Supervises professionalstaff and coordinates functions of the medical records review anddrug utilization review program.

* senior Pharmacist (four positions): Professional staff formedical records review and drug utilization review activities.

* Registered Nursing Consultant (thirteen positions): Plans,coordinates and directs activities for medical records reviewfunctions for use in fraud and abuse investigations.

Amendment 93-39Effective 7/1/93Supersedes 89-10Approval, 10/21/94

Revised Submission JUl 2 2 1994

Attachment 1.2-B

AGENCY FOR HEALTH CARE ADMINISTRATIONMEDICAID OFFICE

Description of Staff

Administrative Unit

Director of Medicaid: Directs the program planning anddevelopment of the Florida Title XIX, Medicaid program.

Executive secretary: Acts as personal secretary to theDirector.

Senior Human Services Program Specialist: Serves asadministrative assistant to the Director. Performs officemanagement functions and duties related to special assignmentsand projects.

Program AnalysisAdministrative Unit

Chief: Provides the planning, research, evaluation,analysis and reporting capabilities required by the Medicaidprogram in the areas of fiscal and bUdget planning, data analysisand forecasting, cost reimbursement, and alternative healthplans.

Staff Assistant: Organizes and administers the dailyadministrative and operational functions of the office. Carriesout pUblic relations activities and performs research inconnection with correspondence.

Fiscal Planning. Data and Research Section

senior Management Analyst II/coordinator: Develops thelegislative budget request for Medicaid, represents the agency atthe Social Services Estimating Conference, prepares data analysisand fiscal impacts.

Operations and Management Consultant Manager: Assists withdevelopment of legislative budget requests, prepares and tracksbudget amendments, allocates and tracks the approved operatingbUdget, and assists with drug rebate monitoring and tracking.

Medical/Health Care Program Analyst (five positions):Assists in the development of the legislative bUdget request andforecast, monitors and amends the bUdget, prepares extensivefiscal analyses, responds to all data requests, prepares drugrebate invoices, and tracks rebate receipts.

Amendment 93-39Effective 7/1/93Supersedes 89-10Approval 10/21/94

Revised submission ,1111 2 2 1994

Attachment 1.2-B

Cost Reimbursement Planning and Analysis section

Regulatory Analyst Supervisor (one position): Directs theMedicaid Cost Reimbursement Planning and Analysis Administratorsin the development, coordination and evaluation of Medicaid costreimbursement plans, methodologies, special reimbursement policystudies, and rate-setting functions. .

Medicaid Cost Reimbursement Planning and AnalysisAdministrator (three positions): Develops, directs, coordinates,and evaluates Medicaid cost reimbursement plans, methodologies,special studies, and rate-setting functions.

Administrative Secretary (two positions): Assists with thepreparation and typing of special documents and correspondence.Answers phones, greets the pUblic, and maintains files.

Regulatory Analyst III (seven positions): Performs deskaudits of cost reports for hospitals, nursing homes, intermediatecare facilities for developmentally disabled, federally qualifiedhealth centers, and county pUblic health units that participatein the Medicaid program. Processes changes in ownership offacilities, and performs rate setting functions.

Regulatory Analyst II (three positions): Performs deskaudits of cost reports for hospitals, nursing homes, intermediatecare facilities for developmentally disabled, federally qualifiedhealth centers, and county pUblic health units that participatein the Medicaid program. Processes changes in ownership offacilities, and performs rate setting functions.

Regulatory Analyst I (one position): Assists in desk auditsand rate setting functions.

Medical/Health Care Program Analyst (two positions):Conducts research on cost reimbursement issues and methodologies.Prepares legislative reports and conducts special policy studies.Assists the Medicaid Cost Reimbursement Planning Administrator inthe development and evaluation of Medicaid cost reimbursementplans and methodologies.

senior Human Services Program Specialist (one position):Assists in the development, evaluation, and implementation ofMedicaid cost reimbursement methodologies for institutionalproviders. PromUlgates administrative rules and coordinatesstate plan amendments.

System Project Analyst (two positions): Designs andmaintains the computer system and software for use by all staffin the Cost Reimbursement,section. This system provides storage,retrieval, rate setting, and statistical analysis for allinstitutional provider reimbursement programs.

Amend)1lent 93-39Effective 7/1/93Supersedes 89-10Approval 10/21/94

Revised Submission 'JOe 2 2 IS Q j

Attachment 1.2-B

computer Programmer Analyst II: Assists the system ProjectAnalysts in maintaining the computer system and software andconducting statistical analysis for all institutional providerreimbursement programs.

Data Analysis Section

systems project Administrator: Develops, directs andcoordinates all required systems development and data analysisrequired for the Medicaid office. Supervises preparation ofbUdget forecast and reports. Analyzes computer hardware andsoftware acquisitions and determines appropriate deployment.Develops and supervises rate-setting methodologies for theMedicaid programs.

Systems project Analyst (three positions): Develops andmaintains all required data systems. Performs required dataanalysis for policy decision-making, including budgeting, ratesetting and new program development. Coordinates data exchangewith the fiscal agent, including ad hoc reporting and databaseextracts.

Audit Services Section

Audit Services Administrator (Chief Internal Auditor):Develops, directs, and coordinates audit programs, audits of costreports for nursing homes, and initial fair rental value systemasset base.

Administrative secretary: Assists with preparation andtyping of special documents and correspondence, and maintainsfiles.

Audit Evaluation and Review Analyst (seven positions):Reviews cost reports of nursing homes and intermediate carefacilities for developmentally disabled for acceptability,reviews audit working papers, represents the agency in the appealprocess, and establishes the fair rental value system asset base.

Managed Health CareAdministrative unit

Chief: Provides the planning, development, implementationand monitoring of managed care programs, including home andcommunity based waivers, freedom of choice waivers, prepaidhealth plans, and demonstration grant programs.

Administrative Secretary: Provides secretarial support inorder to maintain smooth work flow and accurate and timelycompletion of work assignments. Organizes and administers dailyadministrative and operational functions of the office.


Revised Submission 'JUl 2 2 1994

Attachment 1.2-B

Home and Community Based Waivers Section

Program Administrator: Supervises the development of theHome and Community Based waivers and special projects.Coordinates the development of interprogram issues.

Administrative secretary: Provides secretarial support inorder to maintain smooth work flow and accurate and timelycompletion of work assignments.

Medical/Health Care Program Analyst (five positions):Develops program policies and procedures for waiver programs,monitors the provision of services and operation of the programs,and provides technical assistance to areas and other agencystaff. Performs special projects as assigned.

* Registered Nursing ConSUltant: Plans, coordinates anddirects activities for the medical review functions and requestsfor exceptions relating to Project Aids Care (PAC).

Health Maintenance organization section

Program Administrator: Supervises the development ofprogram policies and procedures for prepaid health plancontracting, prepaid health plan contracts, and the development,implementation and operation of new prepaid health plan programs.


Medical/Health Care Program Analysts (four positions):Develops prepaid health plan contracts and programs anddemonstration grant projects.

primary Care case Management section

Program Administrator: Supervises the development of theprimary care case management program and the "Healthy Beginnings"contract. Coordinates interprogram issues.


Medical/Health Care Program Analysts (five positions):Develops, expands and monitors the primary care case managementprogram.

Amendment 93-39Effective 7/1/93supersedes 89-10Approval. 10/21/94

Revised SubmissionJUl 2 2 1994

Attachment 1.2-B

Medicaid Third Party Liability and Contract ManagementAdministrative section

Chief: Supervises the development of third party liabilitypolicies and procedures, and manages the contract for fiscalagent services to develop, operate and m~intain the FloridaMedicaid Management Information System.

staff Assistant: Provides administrative support to thechief in order to maintain smooth work flow and timely completionof assignments.

Third Party LiabilityProgram Policy/Resource Development section

Medical Health Care Program Analyst: Coordinates thedevelopment of third party policies and procedures, electronicdata matches, system changes, state plan, action plan, waiverrequests, and System Performance Review. Serves as liaison forstate and federal audits.

Planner IV: Coordinates the development of third partypolicies and procedures, electronic data matches, system changes,state plan, action plan, waiver requests, and System PerformanceReview. Serves as liaison for state and federal audits. .

Casualty section

Insurance Administrator B: Supervises the handling ofcasualty cases and negotiates settlements.

Insurance Specialist III (five positions): Notifiesattorneys and insurance adjusters of Medicaid payment for injurycases, prepares liens, negotiates settlements, and preparesreleases and satisfactions of lien.

Human services Program Records Analyst: Mailsquestionnaires to injured recipients and identifies returnedquestionnaires.

Secretary Specialist: Provides word processing support tothe Casualty and Insurance Resource staff in order to maintainsmooth work flow and timely completion of assignments.

Amendment 93-39Effec"tive 7/1/93Supersedes 89-10Approval 10/21/94

Revised Submission 'JUL 2 2 1994

Attachment 1.2-B

Insurance Resources section

Insurance Administrator B: Supervises the input of thirdparty liability data into the Florida Medicaid ManagementInformation System, reviews claims pended for third partyliability review, monitor cost avoidance activities, monitors thecarrier billing system, and resolves third party liabilityrelated claim problems.

Insurance Specialist III: Answers insurance companyinquiries, instructs providers about billing with third partyliability, reviews claims pended for third party liabilityreview, performs third party liability overrides for force payclaims, and processes Transfer of Assets forms.

senior Clerks (four positions): Processes Insurance CarrierTurn Around Documents, enters third party liability data from HRSform 1293As and SSA form 8019, insurance carrier billings, mailinsurance carrier claims, and follows up on suspected third partyliability.

Research and Training section

Research and Training specialist (three positions):Provides third party liability related training to HRS area staffinvolved in entering third party liability data into the FloridaOnline Recipient Integrated Data Access System, and providestraining to area Medicaid claim resolution staff.

senior Clerk: Provides word processing support to thetrainers.

Accounting section

Accounting services Supervisor: Reviews third partyhospital aUdits, monitors collections from hospital aUdits,approves provider refunds, and reviews the preparation of thethird party liability portion of the HCFA 64 report.

Administrative secretary: Provides word processing supportto the Accounting and Hospital Audit sections, and providesadministrative support to the third party liability office.

Accountant IV: Prepares the third party liability portionof the HCFA 64 report, initiates Medicaid recoupments, andhandles accounting technical problems.

Fiscal Assistant II: Classifies and records deposits inState Automated Management Accounting System.


Revised Submission 'JOE 2 2 199d

Attac~~ent 1.2-8

Fiscal Assistant I Produces cash receipts for all thirdparty liability recoveries, assists with classifying andrecording deposits, and reviews Medicare Part B cash receipts anddenials.

Reoeipts seotion

Aooountant I: Processes provider request for refunds, andperforms third party liability adjustments in Medicaid historyclaim files.

Fiscal Assistant II (two positions): Enters insurancecarrier payments into the carrier billing file, handlesapplications of restitution payments, enters third partyliability payments to adjust paid claim history, and follows upon outstanding claims on hospital audits.

Clerk Speoialist: Receives and opens incoming mail anddistributes to office staff, and prepares mail-in-log of refundchecks.

Hospital Audit seotion

Internal AUditor II (three positions): Conducts on-siteaudits of business records at Medicaid participating hospitalproviders to identify third parties who may be responsible forpaying part or all of hospital services.

Eligibility seotion

Program Administrator: Supervises the development ofeligibility program policies and procedures including newbornprocessing and buy-in. Coordinates the recipient sUbsystem ofthe Florida Medicaid Management Information System and thedevelopment of interprogram issues.

senior Human Servioes Program Speoialist (three positions):Develops program policies and procedures for eligibility ofMedicaid recipients, including States Legalization ImpactAssistance Grant (SLIAG); monitors the provision of service andoperation of programs, and provides technical assistance to theareas and other agency staff.

Administrative seoretary: Assists with typing documents andcorrespondence and maintaining files.


Revised Submission '..1[11 2 2 1994

Attachment L 2-B

Medicaid Contract ManagementAdministrative section

Administrative Secretary: Provides administrative supportto the chief.

senior Clerk: Receives and distributes incoming mail,maintains Customer service Request files, maintains and updatesthe system documentation library, and performs incidental typingand data input.

systems section

systems project Administrator: Responsible for coordinatingthe operations, maintenance, and management reviews of theFlorida Medicaid Management Information System.

systems Project Analyst (two positions): Responsible forall systems hardware and software aspects of the contract forfiscal agent and other services for the Florida Medicaid Program.

Medicaid Management Review Monitor (two positions):Responsible for management information and operations analysisactivities, and monitoring and overseeing the contractor'smanagement.

Contract Administrative section

Medicaid Management Review Monitor: Responsible for overallfiscal administration and operational review of all fIscalaspects of the Medicaid fiscal agent contract.

BUdget Specialist: Assists in the fiscal administration andoperational review of the fiscal agent contract. Preparesextensive fiscal analysis, monitors the fiscal agent bUdget, andassists in preparation of contract documents.

Audit section

Computer Audit Analyst: Plans, conducts and supervises theaudit activities relative to computerized payments made tomedical care providers by the Medicaid fiscal agent.

senior Contract AUditor (three positions): Plans andconducts audit activities relative to computerized payments madeto medical care providers by the Medicaid fiscal agent.


Revised Submission 'JOe 2 2 1994

Attachment 1.2-8

Program DevelopmentAdministrative Unit

Chief: Plans, directs, organizes and coordinates thedevelopment of Medicaid program pOlicies and procedures. Ensuresprogram policies and procedures are consistent as presented inmanuals, administrative rules, and the state plan and are incompliance with federal and state laws ,rules a,ndregulations.Plans and implements Medicaid program provider and consumerrelations activities, exceptional claims resolution, providerenrollment policies, and provider data analysis.

staff Assistant: organizes and administers activities ofthe office from a business manager standpoint and assures theaccuracy and completeness of all outgoing documents.

Medical Health Care Program Analyst: Coordinates thedevelopment of special programs Which impact children. Serves asa liaison to the Department of Education on policy issues thatimpact schools, including Part H and Full Service Schools.

senior Management Analyst II: Coordinates policy andmanagement issues that cross section responsibilities. Serves asa liaison with other bureaus and state agencies on issues thatimpact program development.

Pharmacy SectionHuman Services Analyst: Reviews and resolves claims

processing problems and adjusts drug coverage codes asappropriate. Assists with file maintenance and review ofrequests for changes in coverage status.

Human Services Program Specialist: Coordinates drug filemaintenance, insures accuracy of drug file pricing information,and makes recommendations for changes in coverage policy.Assists with development of provider notices and providerhandbooks.

Medical Health Care Program Analyst (two positions):coordinates system change requests as they affect the prescribeddrug program and assists in development and analysis of ad hocreports for other professional staff. Organizes and manages thedevelopment of provider manuals and training materials.

systems project Analyst (one position): Manages theadministrative and prior authorization network systems, functionsas technical liaison with the fiscal agent and manages datatransfer between the pharmacy unit and the fiscal agent.


Revised Submission 'JOL 2 2 1994

Attac~~ent 1.2-B

Administrative Secretary (three positions): Maintainsoffice management records and correspondence files, processestravel expense requests, reviews incoming correspondence forassignment and outgoing correspondence for accuracy andappropriate format. Coordinates telephone coverage, vacation andleave scheduling and employee training schedules.

senior Clerk (two positions) :management of coverage requests forpreparation of responses to written

Assists with analysis andprior authorized servicesor telephone inquiries.

and

Word Processing Systems Operator: Types outgoingcorrespondence, operates the switch board, refers inquiries toappropriate professional staff, and sorts incoming writtencorrespondence.

* Senior Pharmacist (thirteen positions): Professional stafffor review and processing of prior authorization requests,changes in coverage policy, and coordination of drug utilizationreview activities. Additional duties include analysis ofutilization data for development of rebate agreements withmanufacturers, negotiation with manufacturers and monitoring ofprior authorization, DUR and rebate agreements impact on theprescribed drug program.

* Pharmaceutical Program Manager (three positions):Supervises professional and clerical staff, coordinatesdevelopment of changes in coverage policy, responds to inquiriesand program change notices from the Health Care FinancingAdministration, develops administrative rule revisions, andinsures appropriate functioning of the prior authorization, drugutilization review and enhanced rebate programs.

Long Term Care section

Program Administrator: supervises the development of longterm care program policies and procedures, and coordinates thedevelopment of interprogram issues.



Revised SubmissionJUl 2 2 1994

Attachment 1.2-3

* Registered Nursing Consultant (three positions):Plans, coordinates and directs activities for the medical reviewfunctions and out-of-state prior authorizations. Developsprogram policies and procedures for home health agencies,hospices, and level of care criteria for intermediate carefacilities for the developmentally disabled and nursingfacilities. Responsible for all prior authorization functionsfor the pressure ulcer therapy program.

Medical/Health Care Program Analyst: Plans, coordinates anddirects the activities relating to nursing homes, intermediatecare facilities for the developmentally disabled, and statemental health hospitals.

senior Human services Program specialist (two positions):Develops program policies and procedures for inpatient andoutpatient hospitals and ambulatory surgical centers. Implementsthe functions of the dental and medical prior authorizationrequest activity, and screens prior authorization requests forthe physician consultant review and the utilization reviewfunctions.

Human Services Program Specialist: Responsible for filemaintenance, institutional provider enrollment, and rulecoordination.

senior Clerk: Enrolls institutional providers; and assistswith utilization control, the quarterly HCFA report, andsemiannual HCFA PASSAR report.

Non-Institutional Section

Program Administrator: Supervises the development ofprogram policies and procedures for non-institutional services;supervises the review, analysis and evaluation of policy, itsimplementation and operation; coordinates development of interprogram issues.

Administrative secretary: Provides secretarial support inorder to maintain smooth work flow and timely accurate completionof work assignments.

* Registered Nurse Consultant: Develops and assesses programpolicies and procedures for podiatry services, therapy services,prescribed pediatric extended care centers, medical foster care,and the mUltiple.handicapped assessment team; provides technicalassistance to area staff and other agency staff.

Amendment 93-39Effective 7(1(93Supersedes 89-10Approval 10(21(94

Revised Submission JUL 2 2 1994

p,ttachment 1.2-B

Medical/Health Care Program Analyst (two positions):Develops and assesses program policies and procedures forindependent laboratory services, Clinical Laboratory ImprovementAmendments compliance, portable X-ray services, durable medicalequipment, supplies, orthotics and prosthetics, and enteral andparenteral supplies and equipment. Provides technical assistanceto area staff and other agency staff.

senior Ruman Services Program Specialist (two positions):Develop and assess program policies and procedures for eyeglassesand vision services, prosthetic eyes, hearing aids and hearingservices, emergency and non-emergency transportation, customizedand motorized wheelchairs, prior and services authorization andspecialty item pricing for non-institutional providers; providetechnical assistance to area staff and other agency staff.

Maternal and Child Health section

Program Administrator: Supervises the development ofprogram policies and procedures on non-institutional services;supervises the review and assessment of policy and itsimplementation and operation; and coordinates development ofinterprogram issues.


* Registered Nursing Consultants (three positions):Coordinates and directs the development and preparation ofprogram policies, handbooks, and administrative rules forphysician services, regional perinatal intensive care centers,advanced registered nurse practitioners, family planning,birthing centers, rural health centers, federally qualifiedhealth care centers, county pUblic health units, Medicaidclinical services, and organ transplantation. CoordinatesHealthy Start issues related to Medicaid. Provides technicalassistance to area Medicaid offices.

Medical Health care Program Analyst: Coordinates anddirects the development and preparation of program policies,handbooks, and administrative rules for dental services.Maintains the procedure code file, healthcare cornmon procedurecoding system (HCPCS) for the Florida Medicaid ManagementInformation System, and locally assigned procedure codes.Provides technical assistance to area Medicaid offices.

AInendment 93-39Effective 7/1/93Supersedes 89-10Approval 10/21/94

Revised Submission ".lUI 2 2 199,\

Attachment 1.2-B

Administrative and Medicaid Services Section

Program Administrator: Supervises the development ofprogram policies and procedures for the Early and PeriodicScreening, Diagnosis and Treatment (EPSDT) and community mentalhealth programs. Supervises the development and preparation ofthe state plan, administrative rules and program manuals.Oversees implementation of third party and crossover claimspolicy and procedures, and the claims processing subsystem ofFlorida Medicaid Management Information System, including SystemPerformance Review (SPR) and quality control.


* Registered Nursing Consultant: Coordinates and directs thedevelopment and preparation of program policies, handbooks, andadministrative rules for Early and Periodic Screening, Diagnosisand Treatment program (EPSDT).

Medical Health Care Program Analyst (two positions):Coordinates and directs the development and preparation ofprogram policies, handbooks, and administrative rules forcommunity mental health. Coordinates and directs the developmentof Medicare crossover policy, claims processing quality control,provider handbook coordination, electronic data interchange(EDI), claim form standards, computer training and resourcecoordination. Coordinates and directs the development andpreparation of program policies, handbooks, and administrativerules for chiropractic services.

senior Human Services Program specialist: Develops anddrafts state plan amendments and cooperative agreements. Servesas liaison on the claims processing" subsystem, system performancereview, third party liability, and system documentation. Assistswith the development of Medicare crossover policy.

Human Services Analyst: Prepares and processes state planamendments, and coordinates review and updates to the FederalRegister, Florida Administrative Weekly, State Medicaid Manual,Health Care Financing Administration program memorandums, programissuances, and the Commerce Clearing House pUblications.

Claims Resolution section

Program Administrator: Supervises the planning, directing,monitoring and implementation of claims force payment proceduresso that federal and state audit requirements are met, and servesas the primary consultative source in the area of claimsprocessing policy and procedures for staff statewide.


Revised Submission JO[ 2 2 1994

Attachment 1.2-B

senior Human services program Specialist (three positions):Develops policies for and processes claims force payments,monitors area force payments, resolves eligibility file errorsthat prevent accurate claims payment. Trains staff statewide inthe billing and reimbursement process.

senior Clerk: Researches and compiles the results offindings concerning Medicaid recipient eligibility histories,recipient data affecting claims adjudication, providerentitlement history and associated data for the use of programspecialists in force pay claims activities. Also providessecretarial support in order to maintain smooth work flow andtimely completion of work assignments.

Provider Relations section

Program Administrator: Supervises the planning, directingand coordination of activities relating to provider enrollment,publications, and maintenance of the Medicaid ManagementInformation System provider file. Manages liaison activitieswith all area offices and professional health care associations.

senior Human services program Specialist: Monitors theprovider relations functions of fiscal agent contractor, and theprovider enrollment requirements. Serves as liaison on systemperformance review.

Human Service Program Records Analyst: Oversees providerenrollment, recruitment, and pUblications. Developsconfidentiality policies, monitors the fiscal agent contractor'sprovider files, and submits and maintains remittance voucherbanner messages to providers.

Medical Health Care Analyst (two positions): Directs theplastic Medicaid card project and develops and prepares Medicaidpublications. Serves as field representation liaison, researchesand analyses provider error trends for policy development, andperforms needs assessment for training efforts.


Revised Submiss ion ',JUI 2 2 1994