Section 7 AAC 160.110 - Fiscal audit(a) The department or its designee shall conduct fiscal audits of Medicaid providers their subcontractors, and their grantees. A provider that bills the department is responsible for ensuring that records related to the services bined are kept by employees, subcontractors, and grantees, are maintained in accordance with7 AAC 105.230, and are made available when requested by the department.(b) For purposes of this section, a fiscal audit may include a desk audit, a field audit, or both, to determine the provider's compliance with the requirements of 42 U.S.C. 1396, AS 47.05, AS 47.07, 42 C.F.R. Part 430 - 42 C.F.R. Part 498, and 7 AAC 105 - 7 AAC 160.(c) For purposes of conducting an audit under this section, the provider must allow the department or its designee, the federal government, or the Department of Law access to original financial, clinical, and other records documenting care provided to Medicaid recipients.(d) Except as provided in (e) of this section, the department or its designee will give a provider 30 days' advance notice of an audit to be conducted under this section. The notice will(1) advise the provider that the department or its designee intends to conduct an audit of the provider's records;(2) specify the place where the audit is to be conducted;(3) specify the records that the provider must produce for purposes of the audit;(4) specify the date by which the provider must produce the records and the address to which the records are to be delivered or inspected; and(5) advise the provider that the provisions of 7 AAC 105.240 apply to the production of the records requested.(e) The department or its designee may request and receive immediate access to records and perform an audit of those records without advance notice if the department or it~ designee has reason to believe, based on credible evidence, that the provider is engaging in a course of conduct or performing an act in violation of the requirements specified in (b) of this section. Notwithstanding the provisions of 7 AAC 105.240, the provider shall produce the requested records for an immediate audit under this subsection at the provider's place of business or other location as specified by the department or its designee. To provide immediate access to records under this subsection, the provider must make the records available not later than 24 hours after the request. If the provider is unable to produce the records in that timeframe, the provider shall notify the department, not later than 24 hours after the request, of the reason for the delay together with the estimated timeframe to comply.(f) Following the department's or its designee's audit of a provider's records, the department or its designee will give the provider the written preliminary findings of the audit. The preliminary findings will identify claim-line inaccuracies. The provider has 30 days after the date of the letter informing the provider of the preliminary findings to submit additional documentation or respond to the preliminary findings.(g) The department will issue the final audit report to the provider no more than 60 days after it has considered any documentation or response submitted under (f) of this section and the audit is complete. The final audit report will include audit or review findings and overpayment amounts identified as a result of the audit.(h) If the department finds in the final audit report under (g) of this section that the provider has not complied with the requirements specified in (b) of this section, (1) the department (A) will recoup or require repayment of any identified overpayment amount from the provider; and(B) may require that the provider pay interest on applicable overpayments; interest on overpayments will be calculated in accordance with AS 47.05.200(b); and(2) in addition to actions under (1) of this subsection, the department may take one or more of the following actions: (A) impose sanctions against the provider under 7 AAC 105.400 - 7 AAC 105.490;(B) initiate other administrative or civil actions;(C) refer the matter to another state, federal, or local agency.(i) For purposes of this section, (1) "audit" means the process of obtaining competent evidentiary material about a provider through inspection, observation, inquiry, and confirmation sufficient to support a reasonable basis for determining the provider's compliance with the legal requirements of the Medicaid program;(2) "desk audit" means an audit of a provider conducted by the department or its designee based upon an examination of a provider's records without a visit to the provider's place of business or site where the provider maintains business records;(3) "field audit" means an audit of a provider conducted by the department or its designee based upon an examination of a provider's records with at least one on-site visit to conduct audit procedures at the provider's place of business or site where the provider maintains business records.Eff. 2/1/2010, Register 193; am 10/1/2011, Register 199; am 6/7/2018,Register 226, July 2018Authority:AS 47.05.010
AS 47.05.200
AS 47.07.030
AS 47.07.040
AS 47.07.074