Form CMS-10343 State Plan Preprint for Medicaid Recover Audit Contracto

Revision:
State

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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

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:

Section 1902(a)(42)(B)(ii)(l)
of the Act

The State/Medicaid agency has contracts of the type(s) listed in
section 1902(a)(42)(B)(ii)(l) 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.

Section 1902 (a)(42)(B)(ii)(ll)(aa)
of the Act

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):

TN No.

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Supersedes
TN No.

Approval Date:
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Effective Date:

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Section 1902 (a)(42)(B)(ii)(ll)(bb)
of the Act

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.

Section 1902 (a)(42)(B)(ii)(lll)
of the Act

Section 1902 (a)(42)(B)(ii)(IV)(aa)
of the Act

TN No.

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.

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Approval Date:

Supersedes
TN No.

The State has an adequate appeal process in place for entities
to appeal any adverse determination made by the Medicaid
RAC(s).

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Effective Date:

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Section 1902 (a)(42)(B)(ii)(IV)(bb)
of the Act

Section 1902 (a)(42)(B)(ii)(IV)(cc)
of the Act

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.
TN No.

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Supersedes
TN No.

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Approval Date:

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Effective Date:

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TN No,

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Supersedes
TN No,

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Approval Date:

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Effective Date:

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