SUBCHAPTER 22F ‑ PROGRAM INTEGRITY

 

SECTION .0100 ‑ GENERAL

 

10A NCAC 22F .0101       SCOPE

This Subchapter shall provide methods and procedures to ensure the integrity of the Medicaid program.  Nothing in these procedures is intended, nor shall be construed, to grant any provider any right to participate in the Medicaid program not granted by federal law or regulations.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 108A‑64; 42 C.F.R. 455.1;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1990; May 1, 1984;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10a NCAC 22F .0102       ORGANIZATION

The North Carolina Department of Health and Human Services, Division of Medical Assistance shall perform the duties required by this Subchapter.  The Department or Division may enter into contracts with other persons for the purpose of performing these duties.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 455;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1984;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22F .0103       FUNCTIONS

(a)  The Division shall develop, implement and maintain methods and procedures for preventing, detecting, investigating, reviewing, hearing, referring, reporting, and disposing of cases involving fraud, abuse, error, overutilization or the use of medically unnecessary or medically inappropriate services.

(b)  The Division shall institute methods and procedures to:

(1)           receive and process complaints and allegations of provider and recipient aberrant practices;

(2)           perform preliminary and full investigations to collect facts, data, and information;

(3)           analyze and evaluate data and information to establish facts and conclusions concerning provider and recipient practices;

(4)           make administrative decisions affecting providers, including but not limited to suspension from the Medicaid program;

(5)           recoup improperly paid claims;

(6)           establish remedial measures including but not limited to monitoring programs;

(7)           conduct administrative review or, when legally necessary, hearings except as provided in Subparagraph (b)(8) of this Rule;

(8)           refer for provider peer review those cases involving questions of professional practice.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 108A‑64; 42 C.F.R. 455, Subpart A;

Eff. May 1, 1984;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22F .0104       PREVENTION

(a)  Provider Education.  The Division may at its discretion, or shall upon the request of a provider, conduct on‑site educational visits to assist a provider in complying with requirements of the Medicaid Program.

(b)  Provider Manuals.  The Division will prepare and furnish each provider with a provider manual containing at least the following information:

(1)           amount, duration, and scope of assistance;

(2)           participation standards;

(3)           penalties;

(4)           reimbursement rules;

(5)           claims filing instructions.

(c)  Prepayment Claims Review.  The Division will check eligibility, duplicate payments, third party liability, and unauthorized or uncovered services by means of prepayment review, computer edits and audits, and other appropriate methods of review.

(d)  Prior Approval.  The Division shall require prior approval for certain specified covered services as set forth in the State Plan.

(e)  Claim Forms.  The Division's provider claim forms shall include the following requirements for provider participation and payment.  These requirements shall be binding upon the Division and the providers:

(1)           Medicaid payment constitutes payment in full.

(2)           Charges to Medicaid recipients for the same items and services shall not be higher than for private paying patients.

(3)           The provider shall keep all records as necessary to support the services claimed for reimbursement.

(4)           The provider shall fully disclose the contents of his Medicaid financial and medical records to the Division and its agents.

(5)           Medicaid reimbursement shall only be made for medically necessary care and services.

(6)           The Division may suspend or terminate a provider for violations of Medicaid laws, regulations, policies, or guidelines.

(f)  Pharmacy and Institutional Provider Agreements.  All institutional and pharmacy providers shall be required to execute a written participation agreement as a condition for participating in the N.C. State Medical Assistance Program.

(g)  The Recipient Management LOCK‑IN System.  The Department of Health and Human Services, Division of Medical Assistance, will establish a lock‑in system to control recipient overutilization of provider services.  A lock‑in system restricts an overutilizing recipient to the use of one physician and one pharmacy, of the recipient's choice, provided the recipient's physician can refer the recipient to other physicians as medically necessary.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 108A‑64; 42 C.F.R. Part 455;

Eff. May 1, 1984.

 

10a NCAC 22F .0105       DETECTION

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 108A‑64; 42 C.F.R. Part 455; 42 C.F.R. 455.12–23;

Eff. May 1, 1984;

Repealed Eff. July 1, 2018.

 

10a NCAC 22F .0106       CONFIDENTIALITY

All investigations by the Division concerning allegations of provider fraud, abuse, over‑utilization, or inadequate quality of care shall be confidential, and the information contained in the files of such investigations shall be confidential, except as permitted by State or Federal law or regulation.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 108A‑64; 132-1.3; 42 C.F.R. Part 455; 42 C.F.R. 455.21;

Eff. May 1, 1984;

Amended Eff. May 1, 1990;

Readopted Eff. July 1, 2018.

 

10a NCAC 22F .0107       RECORD RETENTION

All Title XIX and Title XXI providers shall keep and maintain all Medicaid and NC Health Choice financial, medical, or other records necessary to disclose the nature and extent of services furnished to Medicaid and NC Health Choice recipients and claimed for reimbursement. These records shall be retained for a period of not less than five full years from the date of service, unless a longer retention period is required by applicable federal or state law, regulations, or data retention agreements. Upon notification of an audit or upon receipt of a request for records, all records related to the audit or records request shall be retained until notification that the investigation has been concluded.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑63; 108A‑64; 42 C.F.R. Part 455; 42 C.F.R. 455.12– 23; 42 C.F.R. 431.107;

Eff. April 1, 1988;

Readopted Eff. July 1, 2018.

 

SECTION .0200 ‑ PROVIDER FRAUD AND PHYSICAL ABUSE OF RECIPIENTS

 

10A NCAC 22F .0201       DEFINITION OF PROVIDER FRAUD

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 150B-21.6; 42 U.S.C. 1396(b) et seq.; 42 C.F.R. Part 455;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1990; May 1, 1984;

Repealed Eff. July 1, 2018.

 

10a NCAC 22F .0202       INVESTIGATION

(a)  The Division shall conduct a preliminary investigation of all complaints received or allegations of fraud, waste, abuse, error, or practices not conforming to state and federal Medicaid laws and regulations, clinical coverage policies, or the Medicaid State Plan until it is determined:

(1)           whether there are sufficient findings to warrant a full investigation, as set out in Paragraph (b) of this Rule;

(2)           whether there is sufficient evidence to warrant referring the case for civil fraud investigation, criminal fraud investigation, or both; or

(3)           whether there is insufficient evidence to support the allegation(s) and the case may be closed.

(b)  There shall be a full investigation if the preliminary findings support a credible allegation of possible fraud until:

(1)           the case is found to be one of program abuse subject to administrative action, pursuant to Rule .0602 of this Subchapter;

(2)           the case is closed for insufficient evidence of fraud or abuse; or

(3)           the provider is found not to have abused or defrauded the program.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 42 U.S.C. 1396(b) et seq.; 42 C.F.R. Part 455, Subpart A;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1984;

Readopted Eff. July 1, 2018.

 

10a NCAC 22F .0203       REFERRAL TO LAW ENFORCEMENT AGENCY

The Division shall refer credible allegations of provider fraud, defined as provided by 42 C.F.R. 455.2, which is adopted and incorporated by reference with subsequent changes or amendments and available free of charge at https://www.ecfr.gov/, or suspected physical abuse of recipients to the State Medicaid Fraud Control Unit or other law enforcement agency.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; P.L. 95‑142; 42 C.F.R. 455.2; 42 C.F.R. 455.14; 42 C.F.R. 455.15;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1984;

Readopted Eff. July 1, 2018.

 

SECTION .0300 ‑ PROVIDER ABUSE

 

10 NCAC 22f .0301          DEFINITION OF PROVIDER ABUSE

Provider abuse includes any incidents, services, or practices inconsistent with accepted fiscal or medical practices which cause financial loss to the Medicaid program or its beneficiaries, or which are not reasonable or which are not necessary including, for example, the following:

(1)           Overutilization of medical and health care and services.

(2)           Separate billing for care and services that are:

(a)           part of an all‑inclusive procedure,

(b)           included in the daily per‑diem rate.

(3)           Billing for care and services that are provided by an unauthorized or unlicensed person.

(4)           Failure to provide and maintain within accepted medical standards for the community:

(a)           proper quality of care,

(b)           appropriate care and services, or

(c)           medically necessary care and services.

(5)           Breach of the terms and conditions of participation agreements, or a failure to comply with requirements of certification, or failure to comply with the provisions of the claim form.

The foregoing examples do not restrict the meaning of the general definition.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑63; 42 C.F.R. 455, Subpart C;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1984.

 

10A NCAC 22F .0302       INVESTIGATION

(a)  Abusive practices shall be investigated according to the provisions of Rule .0202 of this Subchapter.

(b)  A Provider Summary Report shall be prepared by the investigative unit furnishing the full investigative findings of fact, conclusions, and recommendations.

(c)  The Division shall review the findings, conclusions, and recommendations and make a tentative decision for disposition of the case from among the following administrative actions:

(1)           To place provider on probation with terms and conditions for continued participation in the program.

(2)           To recover in full any improper provider payments.

(3)           To negotiate a financial settlement with the provider.

(4)           To impose remedial measures to include a monitoring program of the provider's Medicaid practice terminating with a "follow‑up" review to ensure corrective measures have been introduced.

(5)           To issue a warning letter notifying the provider that he must not continue his aberrant practices or he will be subject to further division actions.

(6)           To recommend suspension or termination.

(d)  The tentative decision shall be subject to the review procedures described in Section .0400 of this Subchapter.

(e)  If the investigative findings show that the provider is not licensed or certified as required by federal and state law, then the provider cannot participate in the North Carolina State Medical Assistance Program (Medicaid).

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 455.14; 42 C.F.R. 455.15;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. July 1, 1988; May 1, 1984.

 

section .0400 – agency reconsideration review

 

10A NCAC 22F .0401       PURPOSE

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 456;

Eff. December 1, 1982;

Transferred and Recodified from 10 NCAC 26I .0201 Eff. July 1, 1995;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015;

Repealed Eff. July 1, 2018.

 

10A NCAC 22F .0402       RECONSIDERATION REVIEW FOR PROGRAM ABUSE

(a)  The Division shall notify the provider in writing by certified mail of the tentative decision made pursuant to Rule .0302 of this subchapter and the opportunity for a reconsideration of the tentative decision.

(b)  The provider shall be instructed to submit to the Division in writing a request for a Reconsideration Review within 30 business days from the date of receipt of the notice. Failure to request a Reconsideration Review in the specified time shall result in the implementation of the tentative decision as the Division's final decision.

(c)  The Notice of Reconsideration Review shall be sent to the provider within 30 business days from receipt of the request. The provider shall be notified in writing to appear at a specified day, time, and place. The provider may be accompanied by legal counsel if the provider so desires.

(d)  The provider shall provide a written statement to the Hearing Unit prior to the Reconsideration Review identifying any claims that the provider wishes to dispute and setting forth the provider's specific reasons for disputing the determination on those claims.

(e)  The purpose of the Reconsideration Review includes:

(1)           clarification formulation, and simplification of issues;

(2)           exchange and full disclosure of information and materials;

(3)           review of the investigative findings;

(4)           resolution of matters in controversy;

(5)           consideration of mitigating and extenuating circumstances;

(6)           reconsideration of the administrative measures to be imposed; and

(7)           reconsideration of the restitution of overpayments.

(f)  The Reconsideration Review decision shall be sent to the provider, in writing by certified mail, within 30 business days following the date the review record is closed. The review record is closed when all arguments and documents for review have been received by the Hearing Unit. The decision shall state that the provider may request a contested case hearing in accordance with G.S. 150B, Article 3 and 26 NCAC 03 .0103. Pursuant to G.S. 150B‑23(f), the provider shall have 60 days from receipt of the Reconsideration Review decision to request a contested case hearing in the Office of Administrative Hearings. Unless the request is received within the time provided, the Reconsideration Review decision shall become the Division's final decision and no further appeal shall be permitted.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 150B, Article 3; S.L. 2011-375, s. 2; 42 C.F.R. Part 455.512;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

ARRC Objection October 22, 1987;

Amended Eff. November 1, 1988; March 1, 1988; May 1, 1984;

Readopted Eff. July 1, 2018.

 

10A NCAC 22F .0403       PROCESS

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. 456;

Eff. December 1, 1982;

Amended Eff. January 1, 1988; January 1, 1986;

Transferred and Recodified from 10 NCAC 26I .0202 Eff. July 1, 1995;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

SECTION .0500 ‑ PEER REVIEW

 

10A NCAC 22F .0501       GENERAL

10A NCAC 22F .0502       PEER REVIEW ESTABLISHED

10A NCAC 22F .0503       CHOICE OF PROCEDURES

10A NCAC 22F .0504       COMPOSITION OF PEER REVIEW BOARD

10A NCAC 22F .0505       NOTICE OF PEER REVIEW

 

History Note:        Authority G.S. 108A‑25(b); 150B‑11; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. April 15, 1977;

Readopted Eff. October 31, 1977;

Amended Eff. May 1, 1990; January 1, 1987; January 1, 1986; May 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22F .0506       VENUE

10A NCAC 22F .0507       DOCUMENTATION

10A NCAC 22F .0508       PEER REVIEW PROCEDURES

10A NCAC 22F .0509       DISQUALIFICATION OF BOARD MEMBERS

10A NCAC 22F .0510       FAILURE OF PROVIDER TO ATTEND THE REVIEW

 

History Note:        Authority G.S. 108A‑25(b); 150B‑11; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Amended Eff. May 1, 1990; September 1, 1988; January 1, 1987;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

section .0600 – administrative sanctions and recoupment

 

10A NCAC 22F .0601       RECOUPMENT

(a)  The ­Division shall seek full restitution of improper payments, as defined by 42 C.F.R. 431.958, which is adopted and incorporated by reference with subsequent changes or amendments and available free of charge at https://www.ecfr.gov/, made to providers by the Medicaid Program. Recovery may be by lump sum payment, by a negotiated payment schedule, or by withholding from the provider's pending claims the total or a portion of the recoupment amount.

(b)  A provider may seek reconsideration review of a recoupment imposed by the division under Rule .0402 of this Subchapter.

 

History Note:        Authority G.S. 108A‑25(b); 108C-5(g); 42 C.F.R. Part 431, Subpart Q; 42 C.F.R. Part 455, Subpart F; 42 C.F.R. Part 456;

Eff. February 1, 1982;

Amended Eff. May 1, 1984;

Readopted Eff. July 1, 2018.

 

10A NCAC 22F .0602       ADMINISTRATIVE SANCTIONS AND REMEDIAL MEASURES

(a)  The following types of sanctions may be imposed, singly or in combination, by the Medicaid Agency in instances of program abuse by providers:

(1)           Warning letters for those instances of abuse that can be satisfactorily settled by issuing a warning to cease the specific abuse. The letter will state that any further violations will result in administrative or legal action initiated by the Medicaid Agency.

(2)           Suspension of a provider from further participation in the Medicaid Program for a specified period of time, provided the appropriate findings have been made and provided that this action does not deprive recipients of access to reasonable service of adequate quality.

(3)           Termination of a provider from further participation in the Medicaid Program, provided the appropriate findings have been made and provided that this action does not deprive recipients of access to reasonable services of adequate quality.

(4)           Probation whereby a provider's participation is closely monitored for a specified period of time not to exceed one year.  At the termination of the probation period the Medicaid Agency will conduct a follow-up review of the provider's Medicaid practice to ensure compliance with the Medicaid rules.  Notwithstanding his probation, a probationary provider's participation, like that of all providers, is terminable at will.

(5)           Remedial Measures to include:

(A)          placing the provider on "flag" status whereby his claims are remanded for manual review;

(B)          establishing a monitoring program not to exceed one year whereby the provider must comply with pre-established conditions of participation to allow review and evaluation of his Medicaid practice, i.e., quality of care.

(b)  The following factors are illustrative of those to be considered in determining the kind and extent of administrative sanctions to be imposed:

(1)           seriousness of the offense;

(2)           extent of violations found;

(3)           history or prior violations;

(4)           prior imposition of sanctions;

(5)           period of time provider practiced violations;

(6)           provider willingness to obey program rules;

(7)           recommendations by the investigative staff or Peer Review Committees; and

(8)           effect on health care delivery in the area.

When a provider has been administratively sanctioned, the Division shall notify the appropriate professional society, board of licensure, State Attorney General's Office, federal and state agencies, and appropriate county departments of social services of the findings made and the sanctions imposed.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455;

Eff. May 1, 1984;

Amended Eff. December 1, 1995; May 1, 1990.

 

10A NCAC 22F .0603       PROVIDER LOCK-OUT

(a)  The Division may restrict the provider, through suspension or otherwise, from participating in the Medicaid program, provided that:

(1)           Before imposing any restrictions, the Division will give the provider notice and opportunity for review in accordance with procedures established by the Division.

(2)           The Division shows, before so restricting a provider, that in a significant number of proportion of cases, the provider has:

(A)          provided care, services, and items at a frequency or amount not medically necessary, as determined in accordance with utilization guidelines established by the Division; or

(B)          provided care, service, and items of a quality that does not meet professionally recognized standards of health care.

(3)           The Division will assure that recipients do not lose reasonable access to services of adequate quality as a result of such restrictions.

(4)           The Division will give general notice to the public of the restriction, its basis, and its duration.

(b)  Suspension or termination from participation of any provider shall preclude such provider from submitting claims for payment to the state agency.  No claims may be submitted by or through any clinic, group, corporation, or other association for any services or supplies provided by a person within such organization who has been suspended or terminated from participation in the Medicaid program, except for those services or supplies provided prior to the suspension or termination effective date.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455;

Eff. May 1, 1984;

Amended Eff. December 1, 1995.

 

10A NCAC 22F .0604       WITHHOLDING OF MEDICAID PAYMENTS

(a)  The Medicaid Agency shall withhold Medicaid payments in accordance with the provisions of 42 CFR 455.23 which is hereby incorporated by reference including subsequent amendments and editions.  A copy of 42 CFR 455.23 is available for inspection and may be obtained from the Division of Medical Assistance at a cost of twenty cents ($.20) a page.

(b)  The Medicaid Agency shall withhold Medicaid payments in whole or in part to ensure recovery of overpayments, or to implement the penalty provision of the Patient's Bill of Rights.

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455;

Eff. May 1, 1984;

Amended Eff. December 1, 1995.

 

10A NCAC 22F .0605       TERMINATION

 

History Note:        Authority G.S. 108A‑25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455;

Eff. May 1, 1984;

Repealed Eff. July 1, 2018.

 

10A NCAC 22F .0606       TECHNIQUE FOR PROJECTING MEDICAID OVERPAYMENTS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54; 108A‑63; 42 C.F.R. Part 455, Subpart F;

Eff. October 1, 1987;

Temporary Amendment Eff. November 8, 1996;

Amended Eff. August 1, 1998;

Repealed Eff. July 1, 2018.

 

SECTION .0700 – recipient fraud and abuse

 

10A NCAC 22F .0701       DEFINITION OF FRAUD AND ABUSE

(a)  For purposes of this Section the word "person" includes any natural person, association, consortium, corporation, body politic, partnership, or other group, entity or organization.

(b)  Abuse.  The type of abuse to which the Medicaid program is extremely vulnerable is recipient overutilization of medical and health care services for which he or she is eligible.  A recipient may be regarded as overutilizing the program care and services if he or she has been furnished covered items or services at a frequency or amount not medically necessary, as determined in accordance with utilization guidelines established by the State, and the services were furnished at the request of the recipient.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455;

42 C.F.R. Part 456;

Eff. May 1, 1984;

Amended Eff. May 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10a NCAC 22F .0702       GENERAL

The Division will establish a statewide program for the prevention, detection, investigation, referral, prosecution, recoupment of overpayments, and reporting of fraud, abuse, and overutilization due to recipient aberrant practices.  The program will be supervised by the Division and administered by the county departments of social services.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455;

42 C.F.R. Part 456;

Eff. May 1, 1984;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 22, 2015.

 

10A NCAC 22F .0703       WARNING NOTIFICATION

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10A NCAC 22F .0704       RECIPIENT MANAGEMENT LOCK‑IN SYSTEM

(a)  The Division shall have methods and procedures for the control of recipient overutilization of Medicaid benefits. These methods and procedures shall include Lock‑In of a recipient, shown to be an overutilizer, to specified providers of health care and services, as set out in 42 C.F.R. 440.230, 440.260, and 431.54(e), which are adopted and incorporated by reference with subsequent changes or amendments and available free of charge at https://www.ecfr.gov/.

(b)  Prior to implementing Lock-In, the following steps shall be taken:

(1)           Recipient's utilization pattern shall be documented as inappropriate;

(2)           Recipient shall be notified that the State is imposing a Lock‑In procedure;

(3)           Recipient shall be offered the opportunity to select a provider;

(4)           In the event the recipient fails to select a provider, a provider shall be selected for him or her by the Division; and

(5)           Recipient shall receive an eligibility card indicating the selected providers.

(c)  Recipient utilization patterns shall be reviewed to determine if changes have occurred. If the utilization pattern has been corrected, the Lock‑In status shall end; if the utilization pattern remains inappropriate Lock‑In status shall continue.

(d)  The Division may Lock‑In a recipient provided:

(1)           the recipient is given notice and an opportunity for a hearing before imposing restriction, pursuant to G.S. 150B-23; and

(2)           the Division assures that the recipient has reasonable access to Medicaid care and services of adequate quality, as set out in 42 C.F.R. 440.230, 440.260, and 431.54, which are adopted and incorporated by reference with subsequent changes or amendments and available free of charge at https://www.ecfr.gov/.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 108A‑79; 42 C.F.R. 440.230; 42 C.F.R. 440.260; 42 C.F.R. Part 431; 42 C.F.R. 431.54; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Readopted Eff. July 1, 2018.

 

10A NCAC 22F .0705       OVERUTILIZATION SURVEILLANCE (SUR INDICATOR)

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

 

10a NCAC 22F .0706       RECOUPMENT OF Recipient OVERPAYMENTS

The Division ­requires that:

(1)           counties recover recipient responsible overpayments as a debt to the participating local governments;

(2)           counties accept payments from each recipient and give the recipient a receipt for each transaction;

(3)           counties keep a separate accounting for Medicaid repayments on each recipient;

(4)           repayments shall be forwarded to the Division of Medical Assistance utilizing the DMA 7050 form. This shall be done on a monthly basis;

(5)           the recoupment monies that are apportioned to the repayment of federal, State, and county funds shall be made by the State;

(6)           Medical Assistance overpayments shall not be recouped through the reduction of Temporary Assistance for Needy Families (TANF) checks; and

(7)           the Division receives its prorated share of recoupments of recipient overpayments involving multiple programs.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Readopted Eff. July 1, 2018.

 

10A NCAC 22F .0707       REPORTS AND REVIEWS

 

History Note:        Authority G.S. 108A‑25(b); 108A‑64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.