Utah Admin. Code R414-512-3 - Use of Extrapolation Limited
(1)
The Department or a contractor that conducts audits of providers on behalf of
the Department shall:
(a) have on staff or
contract with a medical or dental professional who is experienced in the
treatment, billing, and coding procedures used by the type of provider being
audited; and
(b) use the services
of the appropriate professional described in Subsection R414-512-3(2)(a) if the
provider who is the subject of the audit disputes the findings of the
audit.
(2) The
Department or a contractor may not base a finding of overpayment or
underpayment on extrapolation as defined in Section
63A-13-102, unless:
(a) there is a determination that the level
of payment error involving the provider exceeds a 10% error rate:
(i) for a sample of claims for a particular
service code; and
(ii) over a
three-year period of time;
(b) documented education intervention has
failed to correct the level of payment error; and
(c) the value of the claims for the provider,
in aggregate, exceeds $200,000 in reimbursement for a particular service code
on an annual basis.
(3)
If a contractor intends to implement the use of extrapolation as a method of
auditing claims, the contractor shall, before adopting the extrapolation method
of auditing:
(a) report its intent to use
extrapolation to the Department; and
(b) proceed with the use of extrapolation
only after the Department has granted permission.
(4) If the Department or a contractor
determines Subsection (3)(a) through (b) is applicable to a provider, the
Department or the contractor may use extrapolation only for the service code
associated with the findings .
(5)
If extrapolation is used under this rule, a provider may appeal the results of
the audit based on:
(a) each individual
claim; or
(b) the extrapolation
sample.
(6) Nothing in
this rule limits a provider's right to appeal the audit under Title 63G,
Chapter 4, the Medicaid program and its manual or rules, or other laws or rules
that may provide remedies to providers.
Notes
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