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Provider Update: April 15, 2019

To:                  All ADvantage Providers

Subject:Case Management Violation Review Committee (CMVRC)

The Medicaid Services Unit – ADvantage Administration (MSU-AA) has implemented a new committee to review violations by ADvantage Case Managers to policy, Conditions of Provider Participation, Case Management (CM) Standards and Program Service Standards for the ADvantage Program. Any documentation and evidence regarding allegations of violations may be compiled for presentation and submitted for review by the Case Management Violation Review Committee (CMVRC).

The CMVRC will review information presented, investigate, and render a decision as to whether the offense rises to the occasion of remediation or decertification of the certification credential. The decision will include such points as:

    • frequency of current violation
    • prior violations
    • scope of the violation
    • affect violation has on Member services and safety
    • affect the violation has on the stability of the ADvantage Program

Review Process

The CMVRC will conduct a confidential review of each alleged CM violation on a case by case basis.  Depending on the nature of the offense, the CMVRC will take action that may include a warning letter, Office of Attorney General (OAG) referral, reporting to the licensing authority, or up to and including decertification of ADvantage CM certification.  

Provider Reporting Process

Should the Provider agency become aware of  a CM that has violated policy that rises to the level of such severity that the behavior warrants a review by the CMVRC, please provide the following and submit, via Harmony PQ**, to the MSU-AA for review:

  1. Name of the CM, date(s) of violation(s)
  2. Affected Member's names and Harmony ID#
  3. Detailed summary of violation(s)
  4. Detailed explanation of the action taken by the Provider agency, if applicable
  5. Copies of disciplinary action given to the CM regarding the violation(s), if applicable
  6. All verifiable evidentiary documentation regarding the violation(s), which may include but not be limited to:
    1. Progress notes
    2. EVV records
    3. Signed documents
    4. Documentation of phone calls to the Member to verify issue
    5. Member statement(s)
    6. APS referral
    7. Harmony submissions

**Submission Information

Please submit all information via Harmony PQ, filling out the PQ as you normally would except:

Inquiry Type = CM Violation Referral

Provider Name = Advantage

Do not include the name of your agency in the Provider ID or Provider Name.  By placing "Advantage" in the Provider Name, this will ensure no one at your agency can read the submission.

Please send any questions regarding the information above through the Harmony PQ chapter.

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