Medicaid Claims Documentation

In accordance with 2 CFR part 200, subpart F, the North Carolina Office of the State Auditor (OSA) annually conducts the State Single Audit and accordingly selects a sample of NC Medicaid claims to determine if claims paid by the state were properly supported. During the recent SFY 2018 Single Audit, OSA reviewed claims documentation to ensure payments were made for Medicaid-covered services and to ensure claims followed proper coding and billing rules. Some claims documentation submitted were determined to be inadequate to support payment for services billed and were deemed an error.

Insufficient documentation errors identified in the SFY18 Single Audit included:

• Documentation does not support billed codes/modifiers/claim details
• Licensing/training/credentialing requirements not met
• Required components of service not completed -- provided documentation does not support services appropriate for beneficiary needs
• No documentation of intent to order services and procedures – incomplete or missing signed order or progress note describing intent for services to be provided
• Services not authorized/approved in accordance with program requirements
   

Providers can reduce the likelihood of future documentation errors by:

• Reviewing the monthly Medicaid Bulletin to stay abreast of changes that may impact billing, licensing, training and credentialing requirements
• Using the NCTracks provider portal to access web-based tutorials, classes and training materials to educate themselves and their billing personnel on all aspects of claims submission
• Implementing an internal quality assurance program which includes performing secondary reviews of claims for proper documentation prior to submission as well as performing periodic self-audits on submitted claims
   

Contact medicaid.sa@dhhs.nc.gov with any questions.