Families and Children. Adult, 3) SSI without Medicare Adult, 4) SSI Child and 5) Xxxxxx Care Child, 6) Dual Eligibles, 7) ACA MAGI Adults, and 8) ACA Former Xxxxxx Care Child. Recipient is interchangeable with “Enrollee.” Retrospective Drug Utilization Review (RetroDUR) means a process that involves ongoing and periodic examination of pharmacy Claims data to identify patterns of Fraud, Abuse, gross overuse, or medically unnecessary care and implements corrective action when needed, as required by 42 C.F.R. 438.3(s) and complies with 1927(g) and 42 C.F.R. part 456, subpart K. Risk Adjustment is a method for determining adjustments to the PMPM rate that accounts for variation in health risks among participating Contractors when determining Capitation Rates.
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