No. 27189 (Amendment): R414-1-14. Utilization Control

DAR File No.: 27189
Filed: 05/26/2004, 12:17
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to be in compliance with H.B. 126 (2003), which eliminated the ability to implement the Medicaid program by policy and required that Medicaid policies be put into rule. Utilization control methods that safeguard against unnecessary or inappropriate use of Medicaid services are Medicaid policies that are now set forth by rule. (DAR NOTE: H.B. 126 (2003) is found at UT L 2003 Ch 324, and was effective 05/05/2003.)

 

Summary of the rule or change:

Subsection R414-1-14(3) is added to this rule. This subsection states the responsibility of the agency to put requests for records in writing and to identify the records to be reviewed. It also describes the 30-day requirement for providers to respond to the agency with a complete record that supports claims for payment. Also, Subsection R414-1-14(4) is included in this rule. This subsection describes the refund policy of the Department for services that are not in compliance with state or federal policies and regulations. It also mentions the appeal process for refund determinations. Finally, Subsection R414-1-14(5) is added. This subsection states the Department policy that requires verification of services through adequate records and requires providers to grant access to records. It also mentions the rights of the state when providers do not comply with this requirement.

 

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3; and 42 CFR Part 456

 

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because it implements existing policy provisions that the state Medicaid statute previously allowed to be implemented by policy.

 

local governments:

There is no impact to local governments associated with this rulemaking because it implements existing policy provisions that the state Medicaid statute previously allowed to be implemented by policy.

 

other persons:

There is no impact to other persons associated with this rulemaking because it implements existing policy provisions that the state Medicaid statute previously allowed to be implemented by policy.

 

Compliance costs for affected persons:

There is no impact for affected persons associated with this rulemaking because it implements existing policy provisions that the state Medicaid statute previously allowed to be implemented by policy.

 

Comments by the department head on the fiscal impact the rule may have on businesses:

This rulemaking is necessary to be in compliance with H.B. 126 (2003), which eliminated the ability to implement the Medicaid program by policy and required that Medicaid policies be put into rule. Utilization control methods that safeguard against unnecessary or inappropriate use of Medicaid services are added to this rule. This does not represent a change in practice and therefore should have no fiscal impact on businesses interacting with Medicaid. Scott D. Williams, MD

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

 

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/15/2004

 

This rule may become effective on:

07/16/2004

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-1. Utah Medicaid Program.

R414-1-14. Utilization Control.

(1) The Medicaid agency has implemented a statewide program of surveillance and utilization control that safeguards against unnecessary or inappropriate use of Medicaid services available under the plan. The plan also safeguards against excess payments, assesses the quality of services, and provides for control and utilization of inpatient services as outlined in the Superior Utilization Waiver state implementation plan. The program meets the requirements of 42 CFR Part 456.

(2) In order to control utilization, and in accordance with 42 CFR 440.230(d), services, equipment, or supplies not specifically identified by the Department as covered services under the Medicaid program, are not a covered benefit.

(3) The Medicaid agency may request records that support provider claims for payment under programs funded through the agency. Such requests must be in writing and identify the records to be reviewed. Responses to requests must be returned within 30 days of the date of the request. Responses must include the complete record of all services for which reimbursement is claimed and all supporting services. If there is no response within the 30 day period, the agency will close the record and will evaluate the payment based on the records available.

(4) If Medicaid pays for a service which is later determined not to be a benefit of the Utah Medicaid program or is not in compliance with state or federal policies and regulations, Medicaid will make a written request for a refund of the payment. Unless appealed, the refund must be made to Medicaid within 30 days of written notification. An appeal of this determination must be filed within 30 days of written notification as specified in R410-14-6.

(5) Reimbursement for services provided through the Medicaid program must be verified by adequate records. If these services cannot be properly verified, or when a provider refuses to provide or grant access to records, either the provider must promptly refund to the state any payments received for the undocumented services, or the state may elect to deduct an equal amount from future reimbursements. If the Department suspects fraud, it may refer cases for which records are not provided to the Medicaid Fraud Control Unit for additional investigation and possible action.

 

KEY: Medicaid

[May 19, 2004]July 16, 2004

Notice of Continuation April 30, 2002

26-1-5

26-18-1