CMS-10398-003 Medicaid Recovery Audit Contractor (RAC) Program

RACs At-A-Glance Phase II Screen Mock Ups

State/Territory (Two-letter postal abbreviation)
Submission Date (MM/DD/YYYY)
State Contact for RAC Program Reporting
		Name
		Title
		Office, Group, or Division
		Address 1
		Address 2
		City
		State/Territory		(Drop down-Two-letter postal abbreviation)
		Zip Code
		Telephone
		Email
State RAC Program Information
	 No RAC contract in effect (If so, please check the reason why below.)
			 Exception to implement RAC was approved by CMS  RAC is in procurement status
Number of Medicaid RAC contracts in effect in your State
Please provide website address(es) which Medicaid providers and the public should visit for information or guidance on RAC audits in your State.			250 character limit
			250 character limit
			250 character limit
			250 character limit

RAC Contract Information
	Contractor name, as shown on signed contract
	Contract number or code that your State uses to track the contract (optional)
	Contract period of performance			Month/Day/Year			to		Month/Day/Year
	Is this a multi-state contractual arrangement?		Yes  No 

RAC Fees	Please check which fee structure your State uses to compensate its RAC(s). For overpayments:  Contingency Fee  Flat Fee  Other (please describe) For underpayments:  Contingency Fee  Flat Fee  Other (please describe) Please enter the specific fee amount your State uses to compensate its RAC(s).
	For overpayments:
	 Contingency Fee Percentage
	 Flat Fee
	 Other (please describe)
	For underpayments:
	 Contingency Fee Percentage
	 Flat Fee
	 Other (please describe)