Utilization Review – Quality Assurance/Quality Improvement

Some Medicaid services are subject to utilization review by a Peer Review Organization (PRO) under contract with AHCA. The purpose of the utilization review program is to safeguard against unnecessary and inappropriate medical care rendered to Medicaid recipients. Medical services and/or records are reviewed for medical necessity, quality of care, appropriateness of place of service and length of stay (inpatient hospital).

The following Medicaid services are subject to review by a PRO:

• Inpatient Hospital Services
• Home Health Services
• Community Mental Health Services
• Targeted Case Management
• Home and Community Based Waiver Services for the Developmentally Disabled

The PROs currently under contract with the agency are Keystone Peer Review Organization (KePRO), First Health Services, Inc. and Delmarva Foundation.

KePRO South (Florida) performs prior authorization and concurrent review of specified categories of inpatient hospital fee for-service recipients and is under contract with the agency until December 31, 2008. KePRO South also performs prior authorization of private duty nursing and personal care services for home health care. Additional information on KePRO South may be found at www.keprosouth.com. KePRO (Pennsylvania) performs home health pre-certification reviews, home health retrospective reviews, and home health claims analysis and is under contract with the agency until June 30, 2007. Additional information on KePRO may be found at www.kepro.org. Information on the Inpatient Hospital Medical Services utilization review program is on this site.

First Health Services, Inc. performs Behavioral Health Utilization Management for the State of Florida. This includes statewide prior authorization of psychiatric inpatient services, prior authorization of services for High-Risk recipients, and prior authorization of community mental health services and mental health targeted case management services. First Health manages the Qualified Evaluator Network (QEN). The state has contracted with First Health since January 1997. The current contracts end December 31, 2005. Additional information on First Health may be found at www.florida.fhsc.com.

>Delmarva Foundation performs statewide quality assurance (QA) monitoring for Florida’s Developmental Disabilities Home and Community-Based Waiver Program. Delmarva is under contract with the agency through June 30, 2009. Detailed information about Delmarva’s QA project and resources may be found at www.dfmc-florida.org. Information regarding provider performance measures and service provider demographics is available through a public reporting website, www.flddresources.org.

Utilization Review QA/QI Team:

Agency for Health Care Administration
2727 Mahan Drive
Mail Stop 20
Tallahassee, Florida 32308-5403
Phone: (850) 487-2618
Fax: (850) 414-1721