93.767 Children's Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) 2024-023 Strengthen Controls to Ensure Compliance with Provider Eligibility Requirements of CHIP and the Medical Assistance Program DOM Response: Two instances of no documentation that required ...
93.767 Children's Health Insurance Program (CHIP) 93.778 Medical Assistance Program (Medicaid; Title XIX) 2024-023 Strengthen Controls to Ensure Compliance with Provider Eligibility Requirements of CHIP and the Medical Assistance Program DOM Response: Two instances of no documentation that required fee were collected. DOM Partially Concurs. After a review of the 2 files, DOM has found in one instance an application fee was collected and sent to DOM for processing; however, the receipt of the application fee was not indicated by comments in the system. DOM will work with Gainwell to ensure remedial training is conducted to reduce errors in the future. One (1) instance correlates to an application received before DOM began requiring the fee on October I, 2022. Thirty-eight instances of no documentation that provider's medical license was current and free of limitations. DOM Partially Concurs. After a review of the 38 files, DOM has found in thirty-one (31) instances the license from the board was attached and the checklist completed after the license was not verified by LexisNexis . Two (2) instances were applications approved prior to the Gainwell implementation; however, the licenses remain valid in SFY 2024 and reflect correct effective dates in the system. One (1) instance is a group and does not require license. Four (4) instances the license from the board was manually verified and attached after the license was not verified by LexisNexis; however, there were typographical errors or omissions in the license fields in the system. DOM will ensure Gainwell conducts remedial training to mitigate these errors in the future. Thirty-one instances of no documentation of review prior to approval of provider's application. DOM Does Not Concur. After a review of the 31 files, DOM has verified all applications identified within this finding as being approved by DOM without review have documented comments in the system of record to show a review of each application was conducted prior to approval. This would include Fifteen (15) instances with review notes, requests for missing information (if applicable), etc. entered by reviewers since the Gainwell Go-Live. Sixteen (16) instances with review notes, requests for missing information (if applicable), etc. entered by reviewers prior to the Gainwell Go-Live. Ten instances of no documentation of verified identity and exclusion status of providers using required federal databases prior to application approval. DOM Partially Concurs. After a review of the 10 files, DOM has found in five (5) instances the LexisNexis report indicated the NPI was verified. One (I) instance of the NPI not verified by LexisNexis, but the Gainwell Analyst performed a manual search in NPPES and attached the verification results on 11/14/24. Four (4) instances before Gainwell began processing applications. The provider was sent to Digital Harbor for screening. DOM's contractual relationship with Digital Harbor ended in 2016 and the data is no longer available. Agency began revalidation in 2017 by stratifying all providers; however, due to PHE all revalidations were paused. As a result, not all revalidations have been completed. At this time, revalidation dates have been assigned in alignment with CMS guidance and will be completed within CMS required timelines, i.e. 44 months from end of the PHE. One (I) instance has a note indicating revalidation occurred in 2017, but no documentation can be located in the system, which potentially could be attributed to data conversion from the legacy system to the new system. Four instances of no documentation of OIG exclusion checks prior to application approval. DOM Concurs. After a review of the 4 files, DOM has found in three (3) instances contain a comment within EDMS that verifies the providers were sent to Digital Harbor for screening. DOM's contractual relationship with Digital Harbor ended in 2016 and the data is no longer available. Please note: Agency began revalidation in 2017 by stratifying all providers, however due to PHE all revalidations were paused. As a result, not all revalidations have been completed. At this time, revalidation dates have been assigned in alignment with CMS guidance and will be completed within CMS required timelines, i.e., 44 months from end of the PHE. One (1) instance has a note indicating revalidation occurred in 2017, but no documentation can be located in the system, which potentially could be attributed to data conversion from the legacy system to the new system. Two instances of no documentation of collection of the provider's NPI. DOM Concurs. After a review of the 2 files, DOM has found all instances contain a comment within the system which verifies the provider was sent to Digital Harbor for screening. DOM's contractual relationship with Digital Harbor ended in 2016 and the data is no longer available. Eight instances of missing or incomplete documentation of required disclosure details. DOM Partially Concurs. After a review of the 8 files, DOM has found in two (2) instances where the individual provider's date of birth is in the system. Two (2) instances where the individual provider's date of birth is not available as it was not a required element at the time of application. DOM will ensure the date of birth is obtained from the provider and added to the system. Three (3) instances where the organizational provider has all required elements. One (1) instance where the organizational provider's address is not available as it was not a required element at the time of application. The missing data is now required and will be collected at the next revalidation. Four instances of no documentation required screening procedures in accordance with provider's designated risk level. DOM Partially Concurs. After a review of the 4 files, DOM has found in three (3) instances where the individual provider's file contains a comment within EDMS verifies provider was sent to Digital Harbor for screening. DOM's contractual relationship with Digital Harbor ended in 2016 and the data is no longer available. Please note: Agency began revalidation in 2017 by stratifying all providers, however due to PHE all revalidations were paused. As a result, not all revalidations have been completed. At this time, revalidation dates have been assigned in alignment with CMS guidance and will be completed within CMS required timelines, i.e., 44 months from end of the PHE. One ( l) instance the individual provider was screened, and a site visit was conducted (as this provider type was deemed moderate risk at that time) and the documentation is available in the system. DOM Corrective Action Plan: a. In response to the audit findings, the Division of Medicaid (DOM) will collaborate with its Fiscal Agent, Gainwell Technologies, to review all identified issues and implement corrective measures. As part of this effort, mandatory refresher and remedial training will be conducted for Gainwell Provider Enrollment staff. This training will emphasize the requirement for comprehensive and accurate documentation within provider files, including clear, detailed, and supportive comments that fully reflect all actions taken during the enrollment and maintenance processes. Additionally, DOM will implement enhanced oversight and quality assurance monitoring to ensure sustained compliance with documentation standards. DOM notes that certain discrepancies identified in the audit may predate the implementation of the MESA system and the transition to Gainwell Technologies as the Fiscal Agent. Due to system conversion constraints, data limitations, and the absence of complete historical documentation within the current system, DOM's ability to retrospectively validate or remediate these pre-implementation discrepancies is limited. As such, corrective actions will be applied prospectively, with a focus on ensuring accuracy, completeness, and compliance within the current MESA environment moving forward. b. Bill Hardin c. March 31, 2026