Utilization Review - Quality Assurance/Quality Improvement

Prior Authorization and Quality Improvement Contracts

The purpose of the utilization review program is to safeguard against unnecessary and inappropriate medical care rendered to Medicaid recipients. Recipient medical services and/or records are reviewed for medical necessity, quality of care, appropriateness of place of service and length of stay (inpatient hospital). Florida Medicaid manages a number of quality improvement and prior authorization contracts to ensure that Medicaid recipients receive medically necessary, quality services in the most cost effective manner.

The following Medicaid services are subject to review for quality improvement or prior authorization:

The organizations providing quality improvement or prior authorization services currently under contract with the Agency are Delmarva Foundation, eQHealth Solutions, Magellan Medicaid Administration, MedSolutions, and Sandata Technologies.

Delmarva Foundation, Inc., a federally-designated Quality Improvement Organization (QIO), provides quality assurance for Florida’s Developmental Disabilities Services system. Delmarva works in partnership with the state’s Agency for Persons with Disabilities at the state and regional offices to improve the quality of supports for Medicaid recipients with developmental disabilities. The developmental services system, called iBudget Florida, gives APD customers more control and flexibility to choose services that are important to them. This program measures the success of services and supports from the blended perspectives of both the individual receiving services as well as program measures and requirements. The goal of this program is to support people to live their everyday lives through quality improvement strategies designed to promote a person directed service delivery system.

eQHealth Solutions, Inc., a federally-designated Quality Improvement Organization (QIO), provides utilization management of Florida Medicaid services, including prior authorization of inpatient medical and surgical, prescribed pediatric extended care therapies, durable medical equipment (DME), dental, hearing, vision, and home health services. Reviews for home health services have recently expanded to include care coordination services for individuals under 21 years of age in skilled nursing facilities, receiving prescribed pediatric extended care, or receiving private duty nursing services. Care coordination includes home visits, monthly phone calls, and bi-annual multi-disciplinary team meetings that include the recipient’s health care team to determine the most appropriate services for the recipient.

Magellan Medicaid Administration, Inc. is the Quality Improvement Organization-like vendor for Florida Medicaid behavioral health programs. They are contracted to perform utilization management functions for fee-for-service community behavioral health and targeted case management providers. Magellan is required to certify and enroll Medicaid providers, to ensure quality of services, and to assist in the prevention and detection of Medicaid program fraud and abuse. Magellan monitors compliance with service eligibility determination procedures, service authorization, policy, staffing requirements, and service documentation requirements in accordance with 409.913 Florida Statutes.

MedSolutions performs prior authorization utilization management for outpatient diagnostic imaging services and utilizes real-time predictive modeling and evidence-based criteria in the decision-making process. This prior authorization utilization management process facilitates increased efficiency and cost effectiveness; and ensures that Medicaid recipients receive the most clinically appropriate advanced imaging services according to approved clinical guidelines.

Sandata Technologies, LLC, verifies the utilization and delivery of home health services and provides an electronic billing interface for home health services. The Telephonic Home Health Services Delivery Monitoring and Verification Program requires providers to submit claims for home health visits electronically through the vendor’s system. Home health visits are verified by telephone using a technology called voice biometrics. Sandata maintains databases for each home health agency in the program. The databases contain information on home health agency staff, recipients, service authorizations, visit schedules, visit verification, and billing activity.

Utilization Review QA/QI Team:

Agency for Health Care Administration
2727 Mahan Drive
Mail Stop #20
Tallahassee, Florida 32308-5403
Phone: (850) 412-4003
Fax: (850) 414-1721