Prepayment review. In the event Contractor subjects a Network Provider to prepayment review or any review requiring the Provider to submit documentation to support a claim prior to the Contractor considering it for payment as a result of suspected Fraud, Waste, Abuse, mismanagement, or misconduct, Contractor shall adhere to the following within ninety (90) days of requiring such action:
5.35.9.1 Conduct a medical and coding review on the claims subject to prepayment review. When Fraud, Xxxxx, Abuse, mismanagement, or misconduct is still suspected after conducting the review, submit to the OIG a suspected Fraud referral, including all referral components as required by the OIG.
5.35.9.2 A prepayment review shall not be conducted for a Provider listed as under investigation or litigation involving the federal or state government or other circumstances as deemed appropriate by the OIG.
Prepayment review. If the Contractor subjects a provider to prepayment review or any review requiring the provider to submit documentation to support a claim prior to the Contractor considering it for payment, as a result of suspected Fraud, Waste and/or Abuse, the Contractor must obtain written consent from MDHHS- OIG prior to placing any providers on prepayment review. To obtain consent, the Contractor must submit its request to place a provider on prepayment review via the MDHHS-OIG sFTP. Requests must be made using MDHHS-OIGs Prepayment Review Request template and at a minimum include:
i. Subject name, address, phone number, provider NPI and type, and any other identifying information;
ii. Date the Contractor plans to place the subject on prepayment review;
iii. The reason for the prepayment review (i.e., the risk(s) identified);
iv. The data or information relied upon in placing the provider on prepayment review (i.e., how the risk was identified);
v. The specific billing codes that will be subject to prepayment review; and
vi. The documentation to be reviewed by the Contractor prior to approval of the selected claims and how that review will mitigate the risk(s) identified.
Prepayment review. The RAC shall identify Medicare overpayments and underpayments using the post payment claims review process. Any other source of identification of a Medicare overpayment or underpayment (such as prepayment review) is not included in the scope of this contract.
Prepayment review. If the Contractor subjects a provider to prepayment review or any review requiring the provider to submit documentation to support a claim prior to the Contractor considering it for payment, as a result of suspected Fraud, Waste and/or Abuse, the Contractor must notify MDHHS-OIG in accordance with Section XVIB. of this Contract for the method and timing of such reporting.
6. Provision for written policies for all employees of the Contactor, and of any contractor or agent, that provide detailed information about the False Claims Act and other Federal and State laws described in section 1902(a)(68) of the Act, including information about rights of employees to be protected as whistleblowers. Contractor must include in any employee handbook a description of the laws and the rights of employees to be protected as whistleblowers.
7. Provision for the prompt referral of any potential credible allegation of Fraud that the Contractor identifies to MDHHS-OIG. If the credible allegation of Fraud referral results in a suspension issued by MDHHS OIG, the Contractor must defend their credible allegation of Fraud conclusion in any appeal. The Contractor must have written documentation of internal controls and policies and procedures in place that are designed to prevent,detect and report known or suspected Fraud, Waste and Abuse activities.
a. Contractor must refer all potential credible allegations of Contractor employee and provider Fraud with an identified overpayment of over $5,000 via MDHHS-OIG’s secure file transfer protocol (sFTP) using MDHHS-OIG’s standard Fraud referral template. All other credible allegations of fraud with an overpayment of less than $5,000 must be
i. Contractor questions regarding whether suspicions should be classified as Fraud, Xxxxx and Abuse should be presented to MDHHS-OIG for clarification.
