Utah Administrative Code
The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (see Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).
NOTE: For a list of rules that have been made effective since January 1, 2020, please see the codification segue page.
NOTE TO RULE FILING AGENCIES: Use the RTF version for submitting rule changes.
R30. Administrative Services, Inspector General of Medicaid Services (Office of).
Rule R30-1. Office Procedures.
As in effect on January 1, 2020
Table of Contents
- R30-1-1. Purpose.
- R30-1-2. Authority.
- R30-1-3. Definitions.
- R30-1-4. Audit Procedures.
- R30-1-5. Requests for Records.
- R30-1-6. On-site Inspections.
- R30-1-7. Self-Audits.
- R30-1-8. Human Resources.
- Date of Enactment or Last Substantive Amendment
- Authorizing, Implemented, or Interpreted Law
The purpose of this rule is to describe the manner in which the office shall execute the requirements of Title 63A, Chapter 13 and the program integrity functions described in the Memorandum of Understanding and Agreement for Services between the department and the office.
This rule is authorized by Section 63A-13-602.
Terms used in this rule are defined in Section 63A-13-102, in addition:
(1) "audit" means an independent, objective review of a program or process and associated controls to determine the effectiveness, efficiency and or compliance of the program or process.
(1)(a) When commencing an audit, the office's audit unit shall:
(i) contact the entity to be audited to advise the entity an audit will be performed;
(ii) send a written announcement memorandum to the entity when the audit begins; and
(iii) obtain background information from the entity to be used in determining the parameters of the audit.
(b) In the course of the audit, the audit unit shall:
(i) hold an entrance conference with the entity to discuss the scope, objectives and timeframe of the audit;
(ii) obtain information from the entity to conduct the audit; and
(iii) keep the entity apprised of issues that arise and any proposed audit findings or conclusions.
(c) At the conclusion of the audit, the audit unit shall conduct an exit conference with the entity audited to:
(i) review any recommendations resulting from the audit; and
(ii) provide the entity with a draft of the audit report.
(d) The entity shall have fourteen days to respond to the audit unit regarding the findings in the audit report.
(e) The entity's response shall be included in a final audit report, which will then be made available to the public.
(2) The audit unit shall seek to incorporate the audit standards created by the Council of Inspectors General on Integrity and Efficiency, the Association of Inspector Generals, and the Generally Accepted Government Auditing Standards created by the United States Government Accountability Office.
(1) Requests for records sent by the office shall be:
(a) in writing and identify the records to be copied; and
(b) mailed by first class postage to the mailing address on file with the department unless the provider or entity notifies the office in writing of an alternative physical or email address to be used for requests for records.
(2)(a) The records requested shall be returned within thirty calendar days of the date of the written request.
(b) A provider's response to a request for records shall include the complete record of all services and supporting services for which reimbursement is claimed.
(3)(a) If a provider has not provided any records within the first 20 days from the date of a request, the office shall:
(i) verify the request for records was sent to the correct address; and
(ii) attempt to contact the provider before the end of the thirty-day period and remind the provider the records must be provided within 30 days from the date of the original request for records.
(b)(i) If the provider fails to provide any records within the thirty-day period, the office shall notify the provider in writing that the records requested were not received.
(ii) The written notice to the provider shall indicate the provider has an additional 15 days from the date of the notification to submit the records or a credit adjustment on the claim shall be instituted pursuant to Section R414-1-14, the Utah Medicaid General Information Provider Manual, and Section 63G-13-202.
(1)(a) Unless there is a credible allegation of fraud, the office shall contact a provider or entity prior to an on-site inspection.
(b) The notification to the provider or entity shall identify the information sought to be reviewed during the on-site visit.
(2) If a provider is unable to produce records requested by the office during an on-site inspection, the provider shall have fifteen business days to provide a copy of the records to the office.
(1) When billing concerns are identified, the office may send out a self-audit packet to a provider, which notifies the provider of:
(a) the type of potential billing errors identified by the office;
(b) a list of claims, which may have been billed incorrectly;
(c) the policy, which describes how the claims should be billed;
(d) instructions on conducting a self-audit;
(e) information about refunding any payments the provider identifies as an overpayment; and
(f) the period for conducting the self-audit and responding to the office.
(2) Once the time for responding to the self-audit has passed, the office shall review any information received from a provider to determine if the provider has fully resolved the issues identified by the office.
(3) If the office is not satisfied the provider fully addressed the concerns identified by the office, the office may:
(a) contact the provider about the issues, which were not fully resolved;
(b) conduct a full investigation and initiate a recovery action if appropriate; or
(c) close the case.
(4) Participation in the self-audit program does not preclude any entity from pursuing any criminal, civil, or administrative remedies or to obtain additional damages, penalties, or fines related to the subject of the self-audit.
(1) The Department of Human Resource Management rules found in R477 shall apply to all office employees.
(2) All office employees shall comply with the requirements of the office's internal policies and procedures.
Office of the Inspector General of Medicaid Services, Medicaid fraud, Medicaid waste, Medicaid abuse
June 1, 2018
For questions regarding the content or application of rules under Title R30, please contact the promulgating agency (Administrative Services, Inspector General of Medicaid Services (Office of)). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from https://rules.utah.gov/help-rules-who-to-contact/.