1. (1) The department or a contractor that conducts audits of providers on behalf of the department shall:

   1. (a) have on staff or contract with a medical or dental professional who is experienced in the treatment, billing, and coding procedures used by the type of provider being audited; and
   2. (b) use the services of the appropriate professional described in Subsection R414-512-3(2)(a) if the provider who is the subject of the audit disputes the findings of the audit.

2. (2) The department or a contractor may not base a finding of overpayment or underpayment on extrapolation as defined in Section 63A-13-102, unless:

   1. (a) there is a determination that the level of payment error involving the provider exceeds a 10% error rate:

      1. (i) for a sample of claims for a particular service code; and
      2. (ii) over a three-year period of time;
   2. (b) documented education intervention has failed to correct the level of payment error; and
   3. (c) the value of the claims for the provider, in aggregate, exceeds $200,000 in reimbursement for a particular service code on an annual basis.

3. (3) If a contractor intends to implement the use of extrapolation as a method of auditing claims, the contractor shall, before adopting the extrapolation method of auditing:

   1. (a) report its intent to use extrapolation to the department; and
   2. (b) proceed with the use of extrapolation only after the department has granted permission.
4. (4) If the department or a contractor determines Subsection (3)(a) through (b) is applicable to a provider, the department or the contractor may use extrapolation only for the service code associated with the findings.

5. (5) If extrapolation is used under this rule, a provider may appeal the results of the audit based on:

   1. (a) each individual claim; or
   2. (b) the extrapolation sample.
6. (6) Nothing in this rule limits a provider's right to appeal the audit under Title 63G, Chapter 4, the Medicaid program and its manual or rules, or other laws or rules that may provide remedies to providers.

KEY: Medicaid

Date of Last Change: November 10, 2023

Notice of Continuation: December 9, 2025

Authorizing, and Implemented or Interpreted Law: 26B-1-213; 26B-3-108; 26B-3-129