R9-22-521. Program Compliance Audits

A. The Administration shall conduct an onsite program compliance audit of a contractor at least once every three years during the term of the Administration’s contract with the contractor. The Administration may conduct, without prior notice, inspections of contractor facilities or perform other elements of a program compliance audit. B. An audit team may perform any or all of the following procedures: 1. Conduct private interviews and group conferences with members, physicians, other health professionals, and members of the contractor’s administrative staff including, but not limited to, the contractor’s principal management persons; 2. Examine records, books, reports, and papers of the contractor and any management company, and all providers or subcontractors providing health care and other services. The examination may include, but need not be limited to: minutes of medical staff meetings, peer review and quality of care review records, duty rosters of medical personnel, appointment records, written procedures for the internal operation of the health plan, contracts and correspondence with members and with providers of health care services and other services to the plan, and additional documentation deemed necessary by the Administration to review the quality of medical care.