Utah Admin. Code R414-522-5 - Evaluation of Provider Compliance with Electronic Visit Verification Requirements
(1) The
Department shall conduct annual post-payment reviews of claims requiring EVV
for home health care service and personal care service providers to assess
compliance with the requirements.
(2) At random, and for each provider, the
Department selects a calendar month within the previous 12-month period and
includes as part of its audit, claims for which a provider has service dates
and has received reimbursement in the selected month. The Department also
includes in the audit, encounters paid through contracted managed care entities
within the selected month.
(3) For
any claims and encounters for which an associated EVV record cannot be located,
or when the EVV record may not be sufficient to meet the requirements in
Section R414-522-3, the Department shall
present an audit report to the provider and allow for an opportunity to refute
the findings.
(4)
(a) The Department may issue the provider a
corrective action plan and recover funds for claims that do not comply with
Section 26B-3-129. Accordingly, the
Department may apply the financial penalties established in this
subsection.
(b) The Department may
withhold payments to a provider that misses deadlines for data submission until
the provider submits the required data.
(c) The Department may issue an audit finding
to a provider found to have performed PCS or HHCS without submitting EVV
records by the required date of compliance. The provider is subject to
recoupment of up to 25% of paid amounts for services that require EVV records
for the month audited as well as up to the two months before the month
audited.
(d) The Department may
impose, for a provider that fails to remedy an audit finding, a recoupment of
up to 100% of paid amounts for services that require EVV records for the month
audited as well as up to the two months before the month audited.
(5) A provider may request an
exemption from penalties if the provider makes a good faith effort, but could
not implement an EVV solution in time due to circumstances beyond the
provider's control. A provider must submit an exemption request to the EVV
email within two weeks of being notified of the finding and recoupment. The
Department reviews exemption requests and decides within two weeks of receiving
the request whether the request meets exemption requirements. Exemption
requests are handled on a case-by case basis.
(6) A provider may request consideration
through the fair hearing process.
Notes
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