Ala. Admin. Code r. 560-X-4-.03

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-4-.03 - Method

(1) Acquire, organize, and analyze data.

(2) Present computer results through special reports that will enable Program Integrity to accomplish the following:

(a) Develop a comprehensive statistical profile of health care delivery and utilization patterns.

(b) Reveal suspected instances of potential fraud, waste, and/or abuse by individual practitioners, providers, recipients, or sponsors of recipients.

(c) Provide information indicating the existence of any potential deficiencies in the level of care or quality of services provided under the Medicaid Program.

(d) Provide information indicating the existence of any potential deficiencies in State resolution procedures.

(3) Conduct in-house and on-site reviews/investigations to obtain additional facts and/or evidence to substantiate suspicions or allegations. Alabama Medicaid staff shall properly identify themselves to providers or recipients as representing the Alabama Medicaid Agency. They shall request information that they consider pertinent to the audit/investigation. Request shall be made directly to the provider, administrator, or person designated in charge.

(4) Prepare and present reviews/investigation findings for prosecution, corrective action and/or sanction.

(5) Provide information identifying deficiencies in documented policy and intended application.

(6) Assures that the Medicaid Agency complies with the process for screening providers in accordance with 42 CFR 455 Subparts B and E.

Ala. Admin. Code r. 560-X-4-.03

Rule effective October 1, 1982. Amended effective November 10, 1988. Repealed and Replaced: Filed February 7, 1994; effective March 15, 1994. Amended: Filed February 20, 1996; effective March 24, 1996.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 12, September 28, 2018, eff. 10/26/2018.

Author: Jacqueline G. Thomas, Director, Program Integrity Division

Statutory Authority: State Plan; Title XIX, Social Security Act;

42 C.F.R. §§ 401, 431et seq., 455 et seq., 456 etseq. ; State Medical Manual 11420.6M.