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Prepayment Claims Review
Medicaid programs provide valuable services to a state’s citizens – but they are expensive and complex to administer and, unfortunately, can be targets for financial abuse.

For more than 15 years, CCME has partnered with North Carolina Department of Health and Human Services (NC DHHS) to maintain program integrity and avoid paying claims to providers with potentially fraudulent billing practices. CCME’s Prepayment Claims Review (Prepay) program seeks to ensure that claims presented by a provider to the NC DHHS for payment meet federal and state laws and regulations and medical necessity criteria in advance of payment. This is achieved through comprehensive manual, clinically focused reviews performed by CCME under a contract with DMA’s Program Integrity (PI) Unit.

Our review staff includes:

  • Registered nurses (generally with psychiatric experience and background)
  • Licensed clinical social workers
  • Other qualified professionals (depending upon the type of provider and/or service under review)

CCME has a highly efficient and cost-effective Prepay program with a history of significant cost-savings and return on investment (ROI). CCME has helped save NC DHHS tens of millions of dollars in net cost-avoidance savings.

NC DHHS rules outline grounds for being placed on review status, which include, but are not limited to, receipt by NC DHHS of credible allegations of fraud, identification of aberrant billing practices as a result of investigations or data analysis performed by NC DHHS, or other grounds as defined by NC DHHS.

For more information, please contact our prepayment claims review staff.