An entity that wishes to perform the functions of a Medicaid RAC must enter into a contract with a State to carry out any of the activities described in § 455.506 under the following conditions:
(a) The entity must demonstrate to a State that it has the technical capability to carry out the activities described in § 455.506 of this subpart. Evaluation of technical capability must include the employment of trained medical professionals, as defined by the State, who are in good standing with the relevant State licensing authorities, where applicable, to review Medicaid claims.
(b) The entity must hire a minimum of 1.0 FTE Contractor Medical Director who is a Doctor of Medicine or Doctor of Osteopathy in good standing with the relevant State licensing authorities and has relevant work and educational experience. A State may seek to be excepted, in accordance with § 455.516, from requiring its RAC to hire a minimum of 1.0 FTE Contractor Medical Director by submitting to CMS a written request for CMS review and approval.
(c) The entity must hire certified coders unless the State determines that certified coders are not required for the effective review of Medicaid claims.
(d) The entity must work with the State to develop an education and outreach program, which includes notification to providers of audit policies and protocols.
(e) The entity must provide minimum customer service measures including:
(1) Providing a toll-free customer service telephone number in all correspondence sent to providers and staffing the toll-free number during normal business hours from 8:00 a.m. to 4:30 p.m. in the applicable time zone.
(2) Compiling and maintaining provider approved addresses and points of contact.
(3) Mandatory acceptance of provider submissions of electronic medical records on CD/DVD or via facsimile at the providers' request.
(4) Notifying providers of overpayment findings within 60 calendar days.
(f) The entity must not review claims that are older than 3 years from the date of the claim, unless it receives approval from the State.
(g) The entity should not audit claims that have already been audited or that are currently being audited by another entity.
(h) The entity must refer suspected cases of fraud and/or abuse to the State in a timely manner, as defined by the State.
(i) The entity meets other requirements as the State may require.
Title 42 published on 2012-10-01
no entries appear in the Federal Register after this date.
This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.