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 April 1, 2019, please see the codification segue page.
NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
Rule R414-512. Use of Extrapolation in Provider Audits.
As in effect on April 1, 2019
Table of Contents
- R414-512-1. Introduction and Authority.
- R414-512-2. Definition.
- R414-512-3. Use of Extrapolation Limited.
- Date of Enactment or Last Substantive Amendment
- Authorizing, Implemented, or Interpreted Law
This rule implements rulemaking required by Section 26-18-20. It sets forth the conditions under which the Department or one of its contractors may use extrapolation as defined in Section 63A-13-102.
"Contractor" means a contractor or subcontractor of the Department.
(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.
January 11, 2016
For questions regarding the content or application of rules under Title R414, please contact the promulgating agency (Health, Health Care Financing, Coverage and Reimbursement Policy). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.