Utah Admin. Code 414-512-3

Current through Bulletin 2024-11, June 1, 2024

Section 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.

Utah Admin. Code R414-512-3

Adopted by Utah State Bulletin Number 2016-3, effective 1/11/2016

Amended by Utah State Bulletin Number 2020-23, effective 11/23/2020