Author: NC Medicaid OCPI, (919) 527-7700
Health Management System (HMS) is under contract with North Carolina Medicaid as NC Medicaid’s Recovery Audit II Contractor (RAC II), pursuant to Section 6411 of the Patient Protection and Affordable Care Act of 2010. HMS is authorized to audit provider payments and financial records for claims to identify underpayments and overpayments, and to recover any overpayment made to providers. HMS will support DHB in its efforts to combat abusive, fraudulent or overutilization activities through the provision of a comprehensive RAC program. HMS will ensure that Medicaid dollars are spent appropriately by performing identification, validation, recovery, and cost avoidance services that are in accordance with State restricted reviewed time period limitations.
HMS activities will include but not be limited to the following service types:
- Inpatient hospital
- Outpatient hospital
- Long-term care
- Skilled nursing facilities
- Intermediate Care Facilities for persons with Mental Retardation (ICF/MRs)
- Adult Care Homes
- Laboratory and X-Ray
- Hospital and free standing
- Specialized outpatient therapies
- Physical therapy
- Occupational therapy
- Respiratory therapy
- Audiology and speech/language pathology services for all ages
The look-back period for reviewing claims will be no greater than three (3) years from the date of the onset of the review. HMS will use generally accepted and valid auditing, accounting, analytical, statistical and peer-review methods.
Pursuant to 42 CFR 433 Subpart F, the Division of Health Benefits (DHB) must recover or attempt to recover any overpayments made to Medicaid providers to receive full federal financial participation for the NC Medicaid Program. Within thirty (30) days from the date an overpayment becomes final pursuant to N.C.G.S. §108C-2(5), money owed to Medicaid will automatically be recovered from future payment(s).
Any communication about a RAC audit matter should be with HMS or the Division of Health Benefits. Do not, under any circumstances, request the fiscal agent GDIT (NC Tracks) to adjust for the amount or items identified during an audit, as this could result in duplicate recoupment.
If you have questions about this notice, please contact the RAC team at HMS Provider Services toll free at (855) 438- 6415, fax to (855) 278-3489 or email at NCRACII@hms.com . You may also call the Division of Health Benefits Office of Compliance and Program Integrity at (919) 527-7700.