R414-512-3. Use of Extrapolation Limited

  (1) The procedures set forth in Rule R380-400 may be used only if the Department or one of its contractors implements extrapolation pursuant to this rule.

  (2) 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.

  (3) 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.

  (4) 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.

  (5) If the Department or a contractor determines Subsection R414-512-3(3)(a) through (c) is applicable to a provider, the Department or the contractor may use extrapolation only for the service code associated with the findings under that subsection.

  (6) 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.

  (7) 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.