CT HB06583

Commissioner of Administrative Services shall contract with one or more entities to provide clinical code editing technologies and claims audit services for the Department of Correction inmate health services program, effective October 1, 2013.

Clinical code editing technologies must automate review and correction of medical and dental claims, identify errors and prevent overbilling using widely accepted protocols, and flag treatments eligible for Medicaid reimbursement.

Claims audit and recovery services must identify improper payments, audit claims, recover overpayments, and submit Medicaid-eligible claims to Medicaid for payment based on accurate diagnosis and procedure codes supported by medical records.

Contracts may structure payments using percentage of savings achieved, per beneficiary per month, per transaction, case-rate models, or combinations thereof, with performance guarantees ensuring savings exceed contractor costs.

Costs of technologies and services are to be paid from savings generated by claims reviews and recoveries.