Family Support Division

Quality Assurance / Quality Control

Report of MO HealthNet QA/QC Review

QA/QC FINDINGS

Review Number:	Region:
Review Month:	Office:
Individual Name:	Supervisor:
Individual DCN:	Worker:
Last Action:	Case Analyst:
Action Date	QA Manager:	De Ann Ebrite
IM QA/QC Manager:	Angela Rogers

MO HealthNet Level of Coverage:

Discovery	Correct – The overall eligibility determination was correct and no issues or problems were identified during the review of this case. Error – The decision about overall program eligibility was incorrect. Deficiency – The overall eligibility determination was correct but an issue or problem was identified during the review of the case. NSTR – Not Subject To Review
Error Responsibility
Source Of Error
Deficiency
Deficiency
MHN Policy Reference(s)

OFFICE RESPONSE

Send Response To: (For QA/QC completion.)
Office Response Due By: (For QA/QC completion.)

1. Does the local office agree with the Case findings presented by QA/QC?	Yes – If case finding result is incorrect, complete 2-7 and required signatures. No – ESS or CM must contact QAM immediately to discuss why they disagree. Explain:
2. Cause / Reason for error(s):
3. Comment "in detail" on the cause / reason for the error(s):
4. Indicators / clues that could have prevented the error(s):
5. Corrective action(s) taken:	Corrected in MEDES / Record updated Corrected in FAMIS / Record updated Claim established Coverage restored Referral to WIU Other:
5a. Explain detailed actions taken to correct error:
5b. List actions taken on Deficiencies discovered by QA/QC:
6. Preventive corrective action(s) taken:	Discussion with Eligibility Specialist Unit trained Eligibility Specialist trained Corrective action plan established/revised Monitoring of Eligibility Specialist increased Policy / Manual reviewed, please list: Other:
7. Teaching point from finding(s):
Eligibility Specialist Signature:	Date:
Supervisor Signature:	Date:
County Manager Signature:	Date: