N.H. Admin. Code § He-W 521.06

Current through Register No. 50, December 12, 2024

Section He-W 521.06 - Self-Audits

(a) Self-audits may be performed either:

(1) Voluntarily by a provider and unsolicited by the department; or

(2) In response to a request by the department as follows:

a. A notice shall be sent to the provider identifying a specific matter to be addressed via the self-audit; and

b. At a minimum the notice shall provide the timeframe of the claims to audit, specific claims to audit, and the allotted period of time in which to conduct and complete the self-audit.

(b) The provider shall submit, at a minimum, the following information, for all audits initiated by (a) above:

(1) Billing provider name;

(2) Billing provider address;

(3) Billing provider medicaid ID number;

(4) Provider type;

(5) Billing provider tax ID number;

(6) Name, title, address, and telephone number of the designated contact for the provider regarding the self-audit;

(7) Date of service;

(8) Rendering or performing provider name;

(9) Procedure code and description;

(10) Number of units billed as defined in He-W 530.01;

(11) Recipient name and ID number;

(12) Internal control number; and

(13) Description of the non-compliance, for example, services not rendered, up-coding, brand drugs for generics, unqualified staff performing service, incorrect dates of service, incorrect recipient, duplicate services, unbundling, and services not documented.

(c) The provider shall submit all requested documentation to the department within 30 days from the last day of the allotted period of time to complete the audit referenced in (a)(2) above.

(d) Upon completion of department's review of the self-audit, the self-audit shall either be accepted or declined and result in the following:

(1) Accepted self-audits shall result in the issuance of a final findings or action letter stating the amount of money to be repaid and shall provide repayment instructions;

(2) Self-audits that are not accepted shall be returned to the provider for corrections, with an explanation regarding why the self-audit could not be accepted; and

(3) If the documentation in (2) above is found to be incomplete or not submitted as stated in (c) above, the department shall conduct an on-site audit of the provider's records.

(e) Participation in a self-audit does not eliminate the possibility of further review by the department and shall not affect in any manner the department or other regulatory or law enforcement agencies' ability to pursue criminal, civil, or administrative remedies.

(f) The provider shall maintain copies of all self-audit information and documentation for 6 years from date of the department approval of the self-audit results.

N.H. Admin. Code § He-W 521.06

Derived from Number 10, Filed March 7, 2024, Proposed by #13884, Effective 2/22/2024, Expires 2/22/2034 (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521).