State Plan Preprint for Medicaid Recovery Audit Contractor (RAC) Program (CMS-10343)

Revision:

State ___________________________________________________

PROPOSED SECTION 4 - GENERAL PROGRAM ADMINISTRATION

4.5 Medicaid Recovery Audit Contractor Program

Citation Section 1902(a)(42)(B)(i) of the Social Security Act Section 1902(a)(42)(B)(ii)(I) of the Act Section 1902 (a)(42)(B)(ii)(II)(aa) of the Act Section 1902 (a)(42)(B)(ii)(II)(bb) of the Act Section 1902 (a)(42)(B)(ii)(III) of the Act Section 1902 (a)(42)(B)(ii)(IV)(aa) of the Act Section 1902 (a)(42)(B)(ii)(IV)(bb) of the Act Section 1902 (a)(42)(B)(ii)(IV)(cc) of the Act

____ The State has established a program under which it will contract with one or more recovery audit contractors (RACs) for the purpose of identifying underpayments and overpayments of Medicaid claims under the State plan and under any waiver of the State plan. ____ The State is seeking an exception to establishing such program for the following reasons: ____ The State/Medicaid agency has contracts of the type(s) listed in section 1902(a)(42)(B)(ii)(I) of the Act. All contracts meet the requirements of the statute. RACs are consistent with the statute. Place a check mark to provide assurance of the following: _____ The State will make payments to the RAC(s) only from amounts recovered. _____ The State will make payments to the RAC(s) on a contingent basis for collecting overpayments. The following payment methodology shall be used to determine State payments to Medicaid RACs for recovered overpayments (e.g., the percentage of the contingency fee): _____ The State attests that if the contingency fee rate paid to the Medicaid RAC will exceed the highest rate paid to Medicare RACs, as published in the Federal Register, the State will only submit for FFP up to the amount equivalent to that published rate. _______ The following payment methodology shall be used to determine State payments to Medicaid RACs for underpayments: _____ The State will submit a justification seeking to pay the Medicaid RAC(s) a contingency fee higher than the highest contingency fee rate paid to Medicare RACs as published in the Federal Register. _____ The State has an adequate appeal process in place for entities to appeal any adverse determination made by the Medicaid RAC(s). _____ The State assures that the amounts expended by the State to carry out the program will be amounts expended as necessary for the proper and efficient administration of the State plan or a waiver of the plan. ______ The State assures that the recovered amounts will be subject to a State’s quarterly expenditure estimates and funding of the State’s share. _____ Efforts of the Medicaid RAC(s) will be coordinated with other contractors or entities performing audits of entities receiving payments under the State plan or waiver in the State, and/or State and Federal law enforcement entities and the CMS Medicaid Integrity Program.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time required to complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Supersedes Approval Date: _________ Effective Date: ________

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