How is a provider notified of audit/review/algorithm results?
Draft Audit Report/Preliminary Clinical Review Notice: Once the review of provider information and records is completed, the provider is mailed a draft audit report/preliminary clinical review notice. The provider is given 30 days to respond to the draft audit report/preliminary clinical review notice.
Final Audit Report/Clinical Overpayment Notice: Once the draft audit/preliminary clinical review notice response time is expired or dispute process is completed, the final audit report/clinical overpayment notice is sent to the provider. This audit report/notice contains the final overpayment amount and directives.
The Surveillance/Utilization Branch Overpayment Notice: When a Surveillance/Utilization Branch review or algorithm is completed, an overpayment notice may be issued. This notice contains the final overpayment amount and may contain directives.
What dispute or appeal rights does a provider have in regards to the audit/review or overpayment notice findings?
Draft audits/preliminary clinical review notices: § 1306.4 of Title 29 DCMR
Providers have anywhere from 30 to 60 days (depending on the category of service being delivered and the specific regulations that govern that service) from receipt of the draft audit report or preliminary clinical review notice to dispute the draft audit or preliminary clinical review findings. Providers must submit the dispute in writing, include what findings they are contesting, and supply documentation to support their position.
Final audits/clinical overpayment: In accordance with § 1307.8 of Title 29 DCMR
Providers have 15 days from receipt of the final audit report/clinical review overpayment notice to request an administrative hearing/appeal of the final audit findings. Providers must submit the request in writing, including the basis for contesting the audit, and including a copy of the final audit report. The written request must be served in a manner which provides proof of receipt and must be sent to:
Office of Administrative Hearing
441 4th Street, NW
Suite 450 - North
Washington, DC 20001-2714