30:4D-17.38 Monitoring of long-term care services.
1. a. The Department of Human Services shall monitor the services provided to an individual receiving services under the Medicaid Managed Long Term Services and Supports section 1115 demonstration waiver, in accordance with this section.
b. In the case of an individual who receives services under one of these programs through a managed care organization, the department shall annually perform a review of a sample of the number of encounters the individual has had with the managed care organization in a given month, as compared with the services authorized for the individual by the program, to help ensure efficient utilization of services from the managed care organization.
c. In the case of an individual who receives services under one of these programs through a provider whose claims are processed by a third-party billing agent, the department shall require the third party-billing agent to annually perform a review of a sample of the provider's billing limits and the services provided to the individual, to help ensure that: services are provided if those services are authorized for the individual by the program; and claims are processed if those claims do not exceed the billing limits authorized for the individual by the program.
L.2015, c.153, s.1.
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