N.H. Medicaid Hospice Provider Manual, Vol. II, § 7

The purpose of a Medicaid Surveillance and Utilization Review (SURS) program which, in NH, is

administered by the Department’s Program Integrity Unit is to perform utilization review activities to

identify, prevent, detect, and correct potential occurrences of fraud, waste and abuse. These utilization

review activities are required and carried out in accordance with Federal regulations at 42 CFR 455 and

42 CFR 456, and they are done to ensure that accurate and proper reimbursement has been made, for care,

services and/or supplies that have been provided to a member, and for which a provider has received

payment.

Utilization review activities may be conducted prior to payment, following payment, or both. These

activities include, but are not limited to, conducting provider reviews. These reviews may be selected at

random, generated from member complaints, other providers, anonymous calls, or from the SURS

reporting system.

There are various outcomes that may result from Program Integrity review activities. They include, but

are not limited to:

•

Recovery of erroneous and improper provider payments;

•

Provider education regarding appropriate documentation to support the submission and payment

of claims;

•

Ensuring that the provider has developed a corrective action plan based on the findings of the

review. This includes conducting follow-up reviews to verify that the provider is complying with

the corrective action plan, and continues to provide and bill for services provided to members, in

accordance with the rules and regulations governing the NH Medicaid Program;

•

Potential referral to appropriate legal authorities – including the NH Medicaid Fraud Control Unit

(MFCU) and the Federal Office of Inspector General (OIG);

•

Potential termination from the NH Medicaid Program; or

•

Other administrative actions.

If a provider is found to have abused the NH Medicaid Program requirements, the provider may be

restricted, through suspension or otherwise, from participating in the NH Medicaid Program for a

reasonable period of time. In addition, the provider may also have their claims placed on a prepayment

pend or hold status for additional review by the Program Integrity Unit.

For additional information regarding utilization review, please refer to the SURS – Program Integrity

section of the General Billing Manual – Volume 1.