OH Medicaid

Quality and Utilization Management Program

Since 1985, we have partnered with the Ohio Department of Medicaid (ODM) and its predecessors to review, improve, and assure quality of care and appropriateness of services delivered to Ohio’s Medicaid recipients.

We assist ODM in continuously monitoring and improving the quality and appropriateness of hospital services. Our contracted services include: pre-certification of inpatient and outpatient elective procedures; retrospective medical necessity review of hospital services; and focused quality and utilization improvement studies. These studies incorporate data collection and analysis, feedback sessions with providers, and development of strategies to improve care.

Newsletters and the Pre-certification Manual are available below. The Ohio Medicaid Pre-certification Manual has been developed to give Ohio hospitals and providers the latest information regarding what procedures require precertification, who to call for precertification, and the information necessary to perform a precertification. Click below for the most recent version.

 

In addition, we publish the Ohio Medicaid Quality Monitor, a quarterly newsletter, to help communicate review trends and project information to the doctors, hospitals, and health plans that serve Ohio Medicaid clients. Download or view the Ohio Medicaid Quality Monitors.

Contact Information

Questions or inquiries regarding the Ohio Medicaid Retrospective Review Program can be sent to Michelle Armstrong (marmstrong@hms.com), Service Line Manager.

For questions about provider claims, please call ODM at 1-(800) 686-1516.