53-6-1404. Peer review of overpayment findings.
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53-6-1404 . Peer review of overpayment findings.
(a)A provider's request for an administrative review of an overpayment determination may include a request for peer review of any clinical or professional judgment upon which the overpayment determination relies. A clinical or professional judgment includes but is not limited to any clinical or professional judgment upon which the provider's evaluation, treatment, records, coding, or billing is based.
(b)The provider's peer review request must identify each clinical or professional judgment to be reviewed and include a statement of the provider's opinion regarding the identified clinical or professional judgment.
(2)If a provider requests peer review, the department shall obtain and consider as part of its administrative review a peer review of each clinical or professional judgment upon which the overpayment determination relied. The department shall mail a copy of the peer review to the provider within 10 days of receipt. The department may not issue its administrative review determination or demand or collect repayment of the alleged overpayment until the department has obtained and considered the peer review.
(3)If at any time during an administrative review, appeal, or other legal proceedings regarding an overpayment determination the department relies on a clinical or professional judgment not identified in the initial notice of overpayment determination and for which a peer review was not previously requested, obtained, or considered, the provider may request in writing that peer review be conducted in accordance with this section. The proceedings must be suspended or stayed until the department has obtained, considered, and responded in writing to the peer review.