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RULE §354.1450Audits of Medicaid Providers

(a) In this section, "provider" means an individual, firm, partnership, corporation, agency, association, institution, or other entity that is or was approved by HHSC to provide Medicaid under contract or provider agreement with HHSC.

(b) This section does not apply to a computerized audit conducted using the Medicaid Fraud Detection Audit System or an audit or investigation conducted by the Medicaid Fraud Control Unit of the Office of the Attorney General, the Office of the State Auditor, the Office of Inspector General, or the Office of Inspector General in the United States Department of Health and Human Services.

(c) Except as described in subsection (b) of this section, an agency auditing division or entity must:

  (1) Notify the provider, and the provider's corporate headquarters, if the provider is a pharmacy that is incorporated, of the impending audit not later than the seventh day before the date the field audit portion of the audit begins;

  (2) Limit the period covered by an audit to three years;

  (3) Accommodate the provider's schedule to the greatest extent possible when scheduling the field audit portion of the audit;

  (4) Conduct an entrance interview before beginning the field audit portion of the audit;

  (5) Audit all providers of the same type under the same standards and parameters;

  (6) Conduct the audit in accordance with generally accepted government auditing standards issued by the Comptroller General of the United States or other appropriate standards;

  (7) Conduct an exit interview at the close of the field audit portion of the audit with the provider to review the agency's initial findings;

  (8) At the exit interview, allow the provider to:

    (A) Respond to questions by the agency;

    (B) Comment, if the provider desires, on the initial findings of the agency; and

    (C) Submit additional supporting documentation, for consideration, that meets the auditing standards required by paragraph (6) of this subsection, to correct a questioned cost, if there is no indication that the error or omission that resulted in the questioned cost demonstrates intent to commit fraud;

  (9) Provide to the provider a preliminary audit report and a copy of any document used to support a proposed adjustment to the provider's cost report;

  (10) Permit the provider to produce, for consideration, documentation to address any exception found during an audit not later than the 10th day after the date the field audit portion of the audit is completed;

  (11) Deliver a draft audit report to the provider not later than the 60th day after the date the field audit portion of the audit is completed;

  (12) Permit the provider to submit, for consideration, a written management response to the draft audit report or to informally appeal the findings in the draft audit report not later than the 30th day after the date the draft audit report is delivered to the provider. The informal appeal will consist of a desk review by the auditing division or entity; and

  (13) Deliver the final audit report to the provider not later than the 180th day after the date the field audit portion of the audit is completed or the date on which a final decision is issued on an appeal made under subsection (d) of this section, whichever is later.

(d) Upon receipt of the final audit report specified in subsection (c)(13) of this section, the provider may request an informal, early review of a final audit report or an unfavorable audit finding by an HHSC ad hoc review panel without the need to obtain legal counsel. All recommendations of the ad hoc review panel are advisory in nature and are not binding on HHSC.

Source Note: The provisions of this §354.1450 adopted to be effective August 1, 2006, 31 TexReg 5799

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