Specifications include, but are not limited to: Determine which Hospitals will be Audited, including: Frequency, in order to maximize the processing of credit balances to the Department. A method for how targeted Audit reviews of in-State, Massachusetts and New Hampshire Hospitals will be identified, including: Determining if an overpayment of Member Claims by MaineCare has occurred, resulting in a credit balance. Performing seventy (70) Audits annually on in-State Hospitals and twelve (12) Audits annually on Hospitals in Massachusetts and New Hampshire. Identify Member inpatient and outpatient Claims paid to the Hospitals, where the Department paid above its legal liability as determined by the MaineCare Benefits Manual (MBM).
