AHCA Logo

Clinical Compliance Monitoring

Darcy Abbott
AHC Administrator

Clinical Compliance Monitoring Unit

Phone: (850) 412-4258

Darcy Abbot

The Clinical Compliance Monitoring Unit is comprised of a multi-disciplinary team of clinical staff, including Behavioral Health Clinicians, Pharmacists, Nurses, and Analysts working together to address clinical care areas of oversight with one focus and goal: to ensure access to quality care in the Medicaid Managed Care environment. The unit has specific expertise in both how the managed care system operates and general health/behavioral health system of care operations, as well as the delivery of services to the Medicaid population. The unit’s functions are as follows:

  • Provide clinical reviews of Statewide Medicaid Managed Care (SMMC) plan reports and initiatives.
  • Perform targeted monitoring of SMMC and Dental contract services to ensure that Medicaid enrollees receive services provided in the quantity and quality required for treatment of the enrollee’s condition, in compliance with the SMMC contract.
  • Review and analyze data submitted by the SMMC and Dental plans for the following reports:
    • Adverse and Critical Incident Summary Report
    • PCP/PDP Appointment Report
    • ER Visits for Enrollees without PCP/PDP Appointment Report
    • Service Authorization Performance Outcome Report
    • Residential Psychiatric Treatment Report
    • Denial, Reduction, Termination or Suspension of Services Report
    • Enhanced Care Coordination Report
    • Case Management File Audit Report
    • Case Manger Caseload Report
    • Enrollee Roster and Facility Residence Report
    • Inter-Rater Reliability Audit
    • Missed Services Report
    • Participant Direction (PDO) Roster Report
    • Provider Network and Qualifications Report
    • Preadmission Screening and Resident Review (PASRR) Report
    • Health Risk Assessment
    • Person-Centered Monitoring (Performance Measures Case File Review)
  • Conduct quality reviews of the following Medicaid programs:
    • Prior Authorizations
    • Medical Foster Care Program
    • Early Intervention Services
    • Medicaid Certified School Match Program
    • Project AIDS Care Waiver
    • Model Waiver
    • Familial Dysautonomia Waiver
    • Pharmacy Reports
  • Participate in interagency child staffing meetings for medical neglect, behavioral health services, and the Children’s Multidisciplinary Assessment Team (CMAT).

2018-2019 Targeted Monitoring Projects

  • Health Risk Assessments
  • Early Intervention Services
  • Transportation
  • Medical Foster Care
  • Telemedicine
  • Expanded Benefits
  • Continuity of Care (SMI)
  • Dental
  • Hospice

Resource Information