Administrative Compliance and Individual Services (ACIS) Reviews
BHDD OIDD contracts with a Quality Improvement Organization (QIO) to complete all Administrative Compliance and Individual Services (ACIS) Reviews. The Key Indicators of compliance for each service area are used to measure each provider’s compliance with BHDD OIDD Service Standards, Directives, and Medicaid Policy/Requirements. Administrative Indicators capture Agency-wide requirements such as staff qualifications and training, and Human Rights Committee and Risk Management Committee Reviews. Services Indicators capture the requirement for the specific service being delivered. Each of the Key Indicators’ documents will state the applicability for different types of providers. In general, Administrative Indicators apply to all providers, although there may be some indicators that only apply to particular service types.
The Provider receives a 48-hour notice for their Administrative Indicator review. This process will apply to the initial reviews and the follow-up Reviews. All new providers will be reviewed between three to six months after accepting their first waiver participant (i.e., during their 12-month probation period).
Individual Record Reviews are initiated without prior notice to the Provider Agency for Case Management, Residential Habilitation, and Day Services. The QIO begins the record review utilizing information available through the electronic record, including Therap and CDSS. The QIO will then arrange a later time to review any information that is not required to be maintained in an electronic format, unless the provider chooses to upload the documentation required for review. This process will be the same for initial reviews and follow-up Reviews. A Plan of Correction will be required for each citation. The action plan should address both the individual citation and systemic corrections.
The purpose of the follow-up review is to ensure remediation of all citations. Typically, this occurs after the Plan of Correction has been submitted and the targeted action plans have been implemented. Most follow-up Reviews occur four (4) to six (6) months after the prior review date. The QIO looks for documentation to verify any citations from the prior review have been corrected and that the provider took steps to prevent similar citations in the future. A follow-up review is limited in size and scope. The only indicators reviewed are those with prior citations. An equal number of new records will also be reviewed to ensure systemic remediation.
Administrative Compliance and Individual Services (ACIS) Review Instruments
In conducting Administrative Compliance and Individual Services (ACIS) Reviews, BHDD OIDD utilizes the following forms and documents:
General Information for FY24 Provider ACIS Reviews (PDF)
ACIS Frequently Asked Questions (PDF)
FY26 Administrative Compliance Review Indicators (PDF)
FY26 Case Management ACIS Indicators (PDF)
FY26 Case Management Crosswalk (PDF)
FY26 Day Services ACIS Indicators (PDF)
FY26 Day Services Crosswalk (PDF)
FY26 Employment ACIS Indicators (PDF)
FY26 Employment Services Crosswalk (PDF)
FY26 Early Intervention ACIS Indicators (PDF)
FY26 Early Intervention Crosswalk (PDF)
FY26 In-Home Supports ACIS Indicators (PDF)
FY26 ILS Services ACIS Indicators (PDF)
FY26 Key Indicator Summary of Changes (PDF)
FY26 Residential Habilitation ACIS Indicators (PDF)
FY25 Administrative Indicators (PDF)
FY25 Case Management ACIS Indicators (PDF)
FY25 Early Intervention ACIS Indicators (PDF)
FY25 Day Services ACIS Indicators (PDF)
FY25 Employment ACIS Indicators (PDF)
FY25 In-Home Supports ACIS Indicators (PDF)
FY25 Residential Habilitation ACIS Indicators (PDF)
Alliant ASO Provider Education Meeting (PDF)
General Workflow of the Provider Administrative Compliance and Individual Services (ACIS) Review Process:
Initial Review
- 12-18 Month Review Cycle, based on Provider's prior performance (Threshold 86%)
- Review concludes within 30 days of start date.
Exit Meeting/Reconsideration Opportunity
- Summary of Preliminary Findings presented at Exit Meeting.
- Providers will have an opportunity to present additional information to reconcile discrepancies.
Report of Findings Issued to Provider
- The findings for Administrative Compliance and Individual Services reviews are merged into a single report for each provider.
- Final ACIS reports are posted in the QIO Portal for each review no later than 45 calendar days from the date of the start of the review.
- Report includes a list of all participants whose records were reviewed, with identifiers for the Waiver type associated with the participant, and the service type(s) the participant is authorized to receive.
Appeal
- Provider may appeal citations in the Report of Findings.
- Contractor will review appeal and provide recommendation to BHDD OIDD
- Upon final determination by BHDD OIDD, Contractor will amend the Report of Findings, as necessary, within 72 hours of receipt of the determination/decision by BHDD OIDD.
Plan of Correction
- Plan of Correction required for all citations - individual and systemic remediation.
- Within 30 days receipt of the specific Report of Findings from the Contractor, the provider will submit a Plan of Correction which addresses the findings in each individual record as well as systemic findings identified by the Contractor.
- The latest completion date for any correction or action will not exceed 90 calendar days following the posting of the Report of Findings in the QIO Portal.
- Accept/reject Plans of Correction.
Follow-up Review
- Follow-up review required to ensure successful implementation of the provider's Plan of Correction.
- Timeframe for follow-up reviews should correspond to the type of citation and length of time needed for remediation, but shall be within 120 calendar days from acceptance of the provider's Plan of Correction.
- Follow-up reviews will include records from the original sample and random selection of new records.
- Report of Findings, Plan of Correction, and Appeal process will follow, similar to the initial review process.
- If the provider is unable to demonstrate remediation, a second follow-up is required.