Utah Admin. Code R414-1-14 - Utilization Control
(1) In order to
control utilization, and in accordance with 42 CFR 440, Subpart B, services,
equipment, or supplies not specifically identified by the Department as covered
services under the Medicaid program are not a covered benefit. In addition, the
Department will also use prior authorization for utilization control . All
necessary and appropriate medical record documentation for prior approvals must
be submitted with the request. If the provider has not obtained prior
authorization for a service as outlined in the Medicaid provider manual, the
Department shall deny coverage of the service.
(2) The Department may request records that
support provider claims for payment under programs funded through the
Department . These requests must be in writing and identify the records to be
reviewed. Responses to requests must be returned within 30 days of the date of
the request. Responses must include the complete record of all services for
which reimbursement is claimed and all supporting services. If there is no
response within the 30 day period, the Department will close the record and
will evaluate the payment based on the records available.
(3)
(a) If
the Department pays for a service which is later determined not to be a benefit
of the Utah Medicaid program or does not comply with state or federal policies
and regulations, the provider shall refund the payment upon written request
from the Department .
(b) If
services cannot be properly verified or when a provider refuses to provide or
grant access to records, the provider shall refund to the Department all funds
for services rendered. Otherwise, the Department may deduct an equal amount
from future reimbursements.
(c)
Unless appealed, the refund must be made to Medicaid within 30 days of written
notification. An appeal of this determination must be filed within 30 days of
written notification as specified in Rule R410-14.
(d) A provider shall reimburse the Department
for all overpayments regardless of the reason for the overpayment.
(e) Provider appeals of action for recovery
or withholding of money initiated by the Office of Inspector General of
Medicaid Services (OIG) shall be governed by the OIG Administrative Hearings
Procedures Manual incorporated by reference in Section
R414-1-5.
Notes
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