Section 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.Utah Admin. Code R414-522-5
Amended by Utah State Bulletin Number 2023-21, effective 10/26/2023