Section 7 AAC 160.140 - Quality assurance program(a) The department, through each division responsible for the administration of the Medicaid program, will establish a quality assurance program to ensure provider compliance with AS 47.05, AS 47.07, and 7 AAC 105 - 7 AAC 160.(b) Under the quality assurance program, the department will conduct program reviews of providers. If the department proposes adverse action as a result of the review, the department will issue a written report of the findings to the provider.(c) If the department finds in the written report under (b) of this section that the provider has not complied with AS 47.05, AS 47.07, or 7 AAC 105 - 7 AAC 160, the department may take one or more of the following actions: (1) give the provider notice under 7 AAC 105.440 that the department proposes to immediately suspend a provider's participation in the Medicaid program;(2) find grounds under 7 AAC 105.400 to sanction the provider under 7 AAC 105.410;(3) require that the provider be subject to a financial audit if there is a reasonable basis to conclude that the provider has received payments in excess of what is authorized under the Medicaid program;(4) require the provider to issue a corrective action plan to address a written report of findings issued under (b) of this section;(5) initiate other administrative or other civil actions;(6) refer the matter to (A) another state, federal, or local agency; and(B) applicable certifying and accrediting agencies.(d) As a condition for participation in the Medicaid program, an ambulatory surgical center or a hospital, including an inpatient hospital, must have in effect a utilization review plan approved by the United States Department of Health and Human Services if utilization review is performed by a federally contracted Quality Improvement Organization (QIO). The written plan submitted by the hospital or the QIO on behalf of the hospital must include the detailed provisions described in 42 C.F.R. 456.50- 456.145, adopted by reference in 7 AAC 160.900.(e) The approved utilization review plan described in (d) of this section must be implemented through the QIO or a hospital that has been delegated review authority by the QIO.(f) As a condition for participation in the Medicaid program, a hospital must participate in a review of health care services to Medicaid recipients. The department or its designee will conduct an annual on-site hospital review under this subsection. The review will be planned in advance and in coordination with the hospital.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 47.07.040