Newsletter February 2023

Quality, Compliance & Customer Service
Kim Zimmerman, MBA-HC, LBSW, CHC
Chief Compliance and Quality Officer

Medicaid Event Verification Site Reviews

Mid-State Health Network (MSHN) has a process for conducting Medicaid Event Verification monitoring and oversight within the Provider Network that is in accordance with the Michigan Department of Health and Human Services (MDHHS) Behavioral Health and Developmental Disabilities Administration (BHDDA) Medicaid Verification Process.

As part of the review, the following attributes are tested:
A.) The code is allowable service code under the contract
B.) Beneficiary is eligible on the date of service
C.) Service is included in the beneficiary’s individual plan of service or in the treatment plan
D.) Documentation of the service date and time matches the claim date and time of the service
E.) Services were provided by a qualified individual and documentation of the service provided falls within the
scope of the service code billed
F.) Amount billed and paid does not exceed contractually agreed upon amount, and
G.) Modifiers are used in accordance with the HCPCS guidelines.

The following are the average compliance percentages for each attribute reviewed for the CMHSPs for FY2022.


The following are the average compliance percentages for each attribute reviewed for the SUD Providers for FY2022.

As a result of the reviews demonstrating the provider network understanding how to submit accurate claims, MSHN has made the following changes to the MEV site review process to begin in FY2023.

  • Community Mental Health Service Participants (CMHSP):
    • Moved from requiring a sample of 5% of the beneficiaries served (with a maximum of 50) to a review of 20 beneficiaries from each CMHSP.
  • Substance Use Disorder (SUD) Providers:
    • Reviews are now coordinated with the Delegated Managed Care site reviews requiring a full review completed biennially and interim review completed during non-full site review year.
    • Sample size will consist of a minimum of 8 beneficiaries during the full review.
    • Sample size will consist of a minimum of 2 beneficiaries during the interim review.

In addition to the above changes, a guidance document is being developed to aid the provider network in providing appropriate supporting documentation for each of the attributes, identify what results in a finding and requires a corrective action plan, as well as provide guidance to providers on when claims will be required to be voided.

These changes will increase efficiencies by making the review process consistent for each CMHSP, provide time
for additional education and training during the reviews, and allowing for more time to review improvements and
corrections implemented to ensure compliance with state and federal standards and MSHNs policies. Overall,
these changes will promote a move towards a process of quality improvement versus focusing solely on corrective

Contact Kim with any questions, comments or concerns related to MSHN Quality, Compliance and Customer Service at