Section 132.42  Post-Payment Review

The State agency may conduct on-site post-payment reviews to determine compliance with this Part and to determine amounts subject to recoupment.

a)         The State agency shall compare billed services to those listed on the ITP or Admission Note in effect at the time service was provided.  The State agency will determine that the following are unsubstantiated:

1)         Billings for services without a completed ITP or Admission Note being in effect, except for mental health assessment; ITP development, review and modification; crisis intervention; transition linkage and aftercare; or mental health case management pursuant to Section 132.165(a)(1);

2)         Billings for services that the provider is not certified to provide;

3)         Billings for services not listed on the ITP or Admission Note, except for mental health assessment; ITP development, review and modification; crisis intervention; transition linkage and aftercare; or mental health case management pursuant to Section 132.165(a)(1); or

4)         Billings that do not comply with the requirements in this Part.

b)         The post-payment review must verify compliance with the requirements identified in subsection (a) of this Section.

c)         The State agency will report its findings to the provider through an Initial Notice of Unsubstantiated Billings.

1)         The initial notice will be sent to the provider within 30 days after the completion of the on-site review.

2)         The provider will have 30 days after the receipt of the initial notice to submit documentation that was not available during the on-site review.  Documentation submitted may not include anything produced following the on-site review.

A)        The State agency will review the additional documentation within 14 days after receipt to determine if it meets the requirements of this Part.

B)        Adjustments will be made to the State agency's findings if the additional documentation meets the requirements of this Part.

d)         The State agency will report the final outcome to the provider through a Final Notice of Unsubstantiated Billings or a Notice of Suspension from Billing.

1)         When a provider receives a Notice of Suspension from Billing, the provider will immediately stop submitting bills for Medicaid community mental health services under this Part.

2)         The provider will have 90 days to make corrections to its documentation processes to bring them into compliance with this Part.

3)         When the provider notifies the State agency in writing that they have made the necessary corrections, the State agency will review them for compliance with this Part within 14 days.

4)         If compliant, the provider will be notified by mail and may resume billing.

5)         The provider may submit bills that have the required documentation for services provided during the suspension.

6)         If corrections are not made within 90 days, the State agency shall revoke the provider's certification.

e)         If the State agency finds evidence of suspected Medicaid fraud or abuse, the State agency shall refer such evidence to HFS, Office of Inspector General for further action.

f)          HFS, in its capacity as the Medicaid single state agency for Illinois, may conduct on- or off-site reviews of payments made by any and all public payers to a provider.

g)         The provider may appeal the State agency's intent to recover funds as specified in Section 132.44.

(Source:  Amended at 32 Ill. Reg. 9981, effective July 1, 2008)