Quality Health Associates provides review of Medicaid utilization as well as preauthorization review. Occasionally, we will engage in focused reviews upon special request.

Quality Health Associates uses InterQual Clinical Decision Support for all Medicaid utilization and quality reviews in North Dakota.

Medicaid Review Process (PDF)


Retrospective Focused Areas of Review

100% Review of the following focused APR-DRG areas:

  • 133 – Pulmonary Edema
  • 138-139 – Pneumonia
  • 203 – Chest Pain
  • 248-251 – Digestive Disorders
  • 421, 422, 425 – Nutritional and Misc. Metabolic Disorders
  • 580-639 – Newborn with Complications
  • 720 – Septicemia
  • 950-952 – Procedures Unrelated to Principal Diagnosis

100% Review of the following focused areas:

  • Psychiatric and Substance Abuse with LOS < 5 days (Codes from Chapter 5 of ICD 10)
  • Review of Readmissions within 15 days (includes readmissions within 7 days)
  • Day Outlier Review
  • Inpatient Admission with LOS 3 days or < excluding normal newborn, and with C-section, and vaginal deliveries
  • Higher Weighted DRGs
  • Special Referrals – (as determined by the State)

Preauthorization Guidance

Areas Requiring Preauthorization

  • 100% screening of admissions to Vibra, Long Term Acute Care Hospitals
  • 100% required Cosmetic Procedures
    – Ear Procedures
    – Nose Procedures
    – Mammoplasties/Gynecomastectomies
    – Facial Surgery
  • 100% Obesity Procedures

Click on the following for more Medicaid preauthorization guidance:

* Please note the two screening criteria sets, Criteria for Bariatric Surgery and Elective Cosmetic Surgery, have been removed. Quality Health Associates uses InterQual Clinical Decision Support for all Medicaid Utilization and Quality Reviews in North Dakota, including prior authorization reviews.