Implementation of Revised Policies Related to Audit LookñBack Period and Provider Response Time for Documentation Requests

This informational bulletin is to notify you of two policies that CMS and the Medicaid Integrity Group (MIG), Program Integrity is implementing to improve the process whereby Audit Medicaid Integrity Contractors (Audit MICs) conduct audits of Medicaid providers. CMS has developed national standards for: • Look-Back period for Auditsestablishes the period of time to five (5) years prior to the start date of the audit, during which time providers claims will be subject to audit. One of the considerations in developing this new policy was whether or not providers maintained records for five years. Research of State audit laws and regulations with regards to how long providers are required to maintain records revealed that most States have at least a five year record retention policy. Furthermore, the Health Insurance Portability and Accountability Act (HIPAA) requires "covered entities" (including providers) to maintain medical records for six years. • Documentation requestexpands the length of time for providers to respond to request for records CMS has approved a revised policy which will allow the provider thirty (30) business days to produce the records. The Audit MIC can authorize a fifteen (15) business day extension if requested, and appropriately justified, by the provider. If the provider needs more than forty-five (45) business days to produce the documents, CMS approval is required. In the latter case, the Audit MIC will send the written request to CMS.

INDUSTRY NEWS TAGS: CMS, Medicaid Missouri

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