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Title: Section 43-2.15 - Audit and claim review

Effective Date


43-2.15 Audit and review.

(a) Providers shall be subject to audit and reviews for quality assurance and proper utilization by the commissioner, his agents or designees. With respect to such audits and reviews, the provider may be required:

(1) to reimburse the department for overpayments discovered by audits; and

(2) to pay restitution for any direct or indirect monetary damage to the program resulting from their improperly or inappropriately furnishing covered drugs, services, supplies or equipment.

(b) The commissioner, his agents or designees, may conduct audits and reviews, and investigate potential fraud or abuse in a provider's conduct.

(c) The commissioner, his agents or designees, may pay or deny claims, or delay claims for audit review.

(d) When audit findings indicate that a provider has provided covered drugs, services, supplies or equipment in a manner which may be inconsistent with regulations governing the program, or with established standards for quality, or in an otherwise unauthorized manner, the commissioner may summarily suspend a provider's participation in the program and/or payment of all claims submitted and of all future claims may be delayed or suspended. When claims are delayed or suspended, a notice of the withholding payment or recoupment shall be sent to the provider by the department. This notice shall inform the provider that within 30 days he/she may request in writing an administrative review of the audit determination before a designee of the commissioner. The review must occur and a decision rendered within a reasonable time after a request for review. If the designee of the commissioner decides withholding or recoupment is warranted, or if no request for review is made by the provider within the 30 days provided, the department shall continue to recoup or withhold funds pursuant to the audit determination.

(e) Where investigation indicates evidence of abuse by a provider, the provider may be fined, suspended, restricted or terminated from the program.


VOLUME A-1 (Title 10)