Montana Code 53-6-1402. Overpayment audit procedures — provider records — limitations on record requests and reviews — onsite audits
53-6-1402. Overpayment audit procedures — provider records — limitations on record requests and reviews — onsite audits. (1) When conducting an overpayment audit, the department or an auditor shall:
Terms Used In Montana Code 53-6-1402
- Auditor: means an individual or an entity, its agents, subcontractors, and employees that have contracted with the department to perform overpayment audits with respect to the medicaid program. See Montana Code 53-6-1401
- Department: means the department of public health and human services provided for in 2-15-2201. See Montana Code 53-6-1401
- Followup audit: means a followup overpayment audit of additional claims data or provider records or both for a particular service code reviewed in an initial overpayment audit after an initial audit has demonstrated a significant error rate with respect to the code to determine whether the provider has complied with applicable medicaid rules, regulations, policies, and agreements. See Montana Code 53-6-1401
- Medicaid: means the Montana medical assistance program established under Title 53, chapter 6. See Montana Code 53-6-1401
- Overpayment audit: means a review or audit by the department or an auditor of claims data, medical claims, or other documents in which a purpose or potential result of the review or audit is an overpayment determination. See Montana Code 53-6-1401
- Provider: means an individual, company, partnership, corporation, institution, facility, or other entity or business association that has enrolled or applied to enroll as a provider of services or items under the medical assistance program established under this chapter. See Montana Code 53-6-1401
- Records: means medical, professional, business, or financial information and documents, whether in written, electronic, magnetic, microfilm, or other form:
(i)pertaining to the provision of treatment, care, services, or items to an individual receiving services under the medicaid program;
(ii)pertaining to the income and expenses of the provider; or
(iii)otherwise relating to or pertaining to a determination of eligibility for or entitlement to payment or reimbursement under the medicaid program. See Montana Code 53-6-1401
- Recovery audit contractor: means a medicaid recovery audit contractor selected by the department to perform audits for the purpose of ensuring medicaid program integrity in accordance with 42 CFR, part 455. See Montana Code 53-6-1401
- Significant error rate: means previous billing errors greater than 5% of the total lines reviewed. See Montana Code 53-6-1401
(a)allow the provider at least 30 days to comply with a request to provide records;
(b)include in a request for records adequate information to allow the provider to identify the particular records sought;
(c)allow providers to submit the requested records in an electronic format; and
(d)allow reasonable extensions of the 30-day compliance period for good cause.
(2)If an auditor is conducting an overpayment audit and requires the provider to provide records in a nonelectronic format, the auditor shall reimburse the provider for the cost of providing the records.
(3)(a) For an initial overpayment audit, the department or an auditor may request up to 6 months of records from a provider for claims paid by the medicaid program up to 3 years before the request was made.
(b)If the department or an auditor demonstrates a significant error rate, the department or the auditor with the department’s approval may request additional records related to the issue under review for purposes of a followup audit.
(c)The 3-year limitation in subsection (3)(a) does not apply to a record request by the department or auditor for purposes of a followup audit but does apply to such a request by a recovery audit contractor.
(4)The department or an auditor may not request records or perform an overpayment audit regarding services that were provided outside the period of time for which providers are required by applicable law to retain records for purposes of the medicaid program.
(5)Except in cases of suspected fraud or criminal conduct, the department or an auditor may not schedule an onsite overpayment audit without first providing written notice at least 10 days in advance of the onsite audit. The department or auditor shall make a good faith effort to establish a mutually agreed-upon date and time for the onsite audit.