Quality assurance and post eligibility reviews

Revised date
Purpose statement

The Health Care Authority or its designee conducts routine case reviews to determine the accuracy of an individual's Apple Health coverage. Individuals are required to provide all information requested during a quality assurance review. There are three types of quality assurance reviews.

  1. Quality assurance reviews conducted by the Division of Program Integrity (DPI): These reviews are conducted according to Federal guidance for the purposes of Medicaid Eligibility Quality Control (MEQC).
  2. Payment Error Rate Measurement (PERM) reviews are conducted every third year by the Center for Medicare & Medicaid Services (CMS).
  3. Post eligibility reviews are conducted on Apple Health approvals for MAGI-based coverage. These reviews target approvals where electronic verification suggests the applicant was not eligible or electronic verification was not present. Refer to the approved Washington State Verification Plan.

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