R414-512-3. Use of Extrapolation Limited

(1) 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. (2) 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. (3) 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. (4) If the department or a contractor determines Subsection (3)(a) through (b) is applicable to a provider, the department or the contractor may use extrapolation only for the service code associated with the findings. (5) 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. (6) 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.