7 AAC 43.067. Reviews and audits

(a) The department, or its representative, may conduct a desk review, field audit, or audit of a provider to determine the provider's compliance with the requirements of 7 AAC 43.030 and other sections of this chapter.

(b) For purposes of conducting a review or audit, the provider shall allow representatives of the department, the federal government, or the Department of Law access to original financial, clinical, and other records documenting care provided to medical assistance patients.

(c) Except as provided in (d) of this section, the department, or its representative, will give a provider reasonable advance notice of a review or audit to be conducted under this section. The notice will

(1) advise the provider that the department, or its representative, intends to conduct a review or audit of the provider's records;

(2) specify the place where the review or audit is to be conducted;

(3) specify the records the provider is requested to produce for purposes of the review or audit;

(4) specify the date by which the provider is requested to produce the records and the address to which they are to be delivered or inspected; and

(5) advise the provider that the provisions of 7 AAC 43.032 apply to the production of the records requested.

(d) The department, or its representatives, may request records and perform an audit or review of those records without advance notice if the department has reason to believe, based on reliable evidence, that the provider is engaging in a course of conduct or performing an act considered in violation of its provider agreement or an applicable statute or regulation and requires immediate access to records. Notwithstanding the provisions of 7 AAC 43.032, the provider shall produce the records as requested for an immediate review or audit of those records at the provider's place of business or other location as specified by the department.

(e) Following the department's, or its representatives', review or audit of a provider's records, the provider may request that it be advised of the status of the review or audit. If requested to do so, the department will advise the provider of the status of the review or audit no later than 30 days after it receives the request.

(f) A review or audit of a provider's records under this section does not preclude the department from taking action to

(1) recoup or recover an overpayment from the provider;

(2) impose sanctions against the provider under 7 AAC 43.950 - 7 AAC 43.985;

(3) initiate other civil or administrative actions; or

(4) refer the matter to another state, federal, or local agency.

(g) For purposes of this section,

(1) "audit" means the process of obtaining competent evidentiary material about a provider, through inspection, observation, inquiry, and confirmation, sufficient to afford a reasonable basis for ascertaining the provider's compliance with the requirements of law applicable to the medical assistance program;

(2) "desk review" means an audit of a provider conducted by the department, or its representative, based upon an examination of a provider's records without a visit to the provider's place of business or site at which the provider maintains business records;

(3) "field audit" means an audit of a provider conducted by the department, or its representative, based upon an examination of a provider's records at the provider's place of business or site at which the provider maintains business records;

(4) "review" means a desk review or a field audit.

History: Eff. 11/29/97, Register 144; am 6/26/98, Register 146; am 6/19/2004, Register 170

Authority: AS 47.05.010

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