Author: Office of Compliance and Program Integrity, 919-814-0172
Every year, in accordance with 2 CFR part 200, subpart F, the NC Office of the State Auditor (OSA) selects a sample of North Carolina Medicaid and NC Health Choice (NCHC) claims to review to determine the state’s compliance with federal and state regulations for claims paid in the prior state fiscal year (SFY), which runs from July 1 to June 30.
The NC Division of Medical Assistance (DMA) Office of Compliance and Program Integrity (OCPI) will send out medical record requests during the fourth quarter of SFY 2018 to providers who have a claim in the randomly selected sample.
To minimize costs and prevent delays, providers who are selected as part of the sampling will receive a call from OCPI to verify the address of the provider’s Compliance Department or Health Information Management Department, where these medical record requests should be mailed.
For inpatient hospital services, OCPI will also request the name and address of the chief financial officer.
The record request will contain a list of the documents to be submitted to OCPI for the initial review of the claim. The requested documents must be sent as soon as possible, but no later than 30 calendar days after the receipt of the medical records request. Providers who have more than 25 pages of documentation must submit the documents on an encrypted CD or flash drive, with the password sent separately via unencrypted email to Medicaid.SA@dhhs.nc.gov. This will prevent payment error findings related to missing documentation.
During the medical record request process, OCPI may ask for additional documentation to support the payment of the claim. Failure to respond in a timely manner may result in placement on prepayment claims review. Providers must follow G.S 108C-11, Cooperation with investigations and audits.
DMA is authorized by Section 1902 (a) (27) of the Social Security Act and 42 CFR. 431.107 to access patient records for purposes directly related to the administration of Medicaid and NCHC. When applying for Medicaid benefits, beneficiaries sign a release which authorizes DMA and other appropriate regulatory authorities to access Medicaid records. Therefore, it is not necessary to secure a signed consent for the release of records from any affected Medicaid beneficiary before submitting the necessary documentation for this review.
Providers with concerns or questions can contact OCPI at 919-814-0172.