53-6-1405. Audit completion -- notice of overpayment determination -- opportunity to resubmit claim.
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53-6-1405 . Audit completion -- notice of overpayment determination -- opportunity to resubmit claim.
(1)The department or an auditor shall conclude an overpayment audit and notify the provider in writing of the audit results, including any overpayment determination, within 90 days of:
(a)the receipt of all records requested in the department's or the auditor's initial record request;
(b)a determination regarding fraud in cases in which the department investigates a credible allegation of fraud; or
(c)the conclusion of an investigation and any related enforcement proceedings if a government agency or entity other than the department is conducting a civil fraud or criminal investigation of the provider and the government agency or entity conducting the investigation determines and notifies the department in writing that providing earlier notification would interfere with or jeopardize the investigation, recovery of a fraudulent overpayment, or criminal prosecution.
(2)A notice of overpayment determination, including any notice of audit results under subsection
(1)that includes a notice of overpayment determination, must include a detailed explanation of the overpayment determination, including at a minimum:
(a)a description of the overpayment;
(b)the dollar value of the overpayment;
(c)the specific reason for the overpayment determination;
(d)the specific medical criteria and any clinical and professional judgment upon which the determination is based;
(e)in cases in which an overpayment resulted from incorrect billing rather than a lack of medical necessity or failure to provide the services or items in accordance with applicable requirements, a statement that the provider may submit a new claim or claim adjustment as provided in 53-6-111 ;
(f)the action to be taken by the department;
(g)an explanation of any action required of the provider; and
(h)an explanation of the provider's right to appeal.