Resources for SMAs

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Resources for State Medicaid Agencies

We have created the resources below to help you successfully manage your state’s Medicaid program integrity activities, train your staff, and educate providers. These resources include best practices on a variety of topics, informative resources about provider requirements, and frequent findings from state program integrity reports. We have also created one-page infographics on relevant topics that are especially useful for training and education.

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The one-page infographics below provide quick overviews of commonly challenging topics in Medicaid. These infographics can be posted in offices or waiting areas and can be used as part of training and education programs for state staff, providers, or beneficiaries.

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Best Practices for State Medicaid Agencies

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Provider Requirements

We have created the resources below to help states with a range of topics in provider management including enrollment, ownership and control, payments, and more. States can also use these resources to educate providers and improve compliance. Most of the resources are short fact sheets that provide high-level information on topics. We also provide frequent findings from State Program Integrity Reviews on select topics in provider management.



Ownership and Control

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Managed Care Toolkits

  • Managed Care Payment Suspensions (PDF)
    This toolkit discusses managed care-related payments suspensions and the procedures in place to suspend payment when there is credible allegation of fraud, consistent with requirements found in 42 CFR 438.608(a)(8). (10 pages)
  • Managed Care Overpayment Recoveries (PDF)
    This toolkit discusses how recoveries of network provider overpayments may be treated. These regulations provide states with flexibility on how to handle recoveries made by MCPs to create incentives for MCPs to proactively oversee network provider billing practices and identify fraud, waste, and abuse. (11 pages)
  • Managed Care Fraud Referral (PDF)
    This Prompt Referrals of Potential Fraud, Waste, or Abuse Toolkit discusses the requirements of MCPs to promptly report and establish clear timelines for referrals of potential fraud, waste, or abuse to the State Medicaid Program Integrity Unit or Medicaid Fraud Control Unit as required. (8 pages)
  • Managed Care Compliance (PDF)
    This Compliance Program Requirements Toolkit discusses the compliance program requirements that states must follow when entering into contracts with MCPs. (12 pages)

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Page Last Modified:
11/01/2023 06:10 AM