Some Medicaid services are subject to utilization review by a Quality Improvement Organization (QIO) 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 QIO:
- Inpatient Hospital Services
- Home Health Services
- Community Behavioral Health Services
- Therapy Services (beginning November 1, 2011)
- Prescribed Pediatric Extended Care Services (beginning November 1, 2011)
- Home and Community Based Waiver Services for the Developmentally Disabled
The QIOs currently under contract with the agency are eQHealth Solutions, Inc., Magellan Medicaid Administration, Inc., and Delmarva Foundation.
eQHealth Solutions, Inc. performs prior authorization and continued stay review of specified categories of inpatient hospital and home health services (which includes home health visits, private duty nursing, and personal care services) for fee for-service and MediPass recipients. The State entered into a contract with eQHealth Solutions to perform these services beginning June 1, 2011 through June 30, 2014. Beginning November 1, 2011, eQHealth Solutions will also perform prior authorization reviews for services provided in a Prescribed Pediatric Extended Care Center and therapy services provided to children under the age of 21. Additional information on eQHealth Solutions may be found at http://fl.eqhs.org.
Magellan Medicaid Administration, Inc. performs behavioral health utilization management for the State of Florida. This includes statewide prior authorization of psychiatric inpatient services, on-site retrospective and quality of care reviews for community behavioral health services, behavioral health overlay services, and Statewide Inpatient Psychiatric Programs. Magellan Medicaid Administration also manages the Qualified Evaluator Network (QEN). The state has contracted with Magellan Medicaid Administration since January 1997. The current contract ends June 30, 2012. Additional information on Magellan Medicaid Administration may be found at 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, 2014. 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) 412-4003
Fax: (850) 414-1721