North Carolina Administrative Code

10A NCAC 22B .0202 FORMS All forms are available through the private contractor mentioned in 10A NCAC 22A .0101. History Note: Authority G.S. 108A-25(b); 108A-54; 143B-10; Eff. February 1, 1976; Readopted Eff. October 31, 1977; Pursuant to G.S. 150B-21.3A, rule is necessary witho…

10A NCAC 22C .0104 HEALTH INSURING ORGANIZATIONS History Note: Authority G.S. 108A-25(b); 34 C.F.R. 434.14; Eff. February 1, 1976; Readopted Eff. October 31, 1977; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

subchapter 22D – recipient issues 10A ncac 22D .0101 CO-PAYMENT History Note: Authority G.S. 108A-25(b); S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.230(d); Tax Equity and Fiscal Responsibility Act of 1982, Subtitle B; Section 95 of Chapter 689, 1991 Session Laws; Eff. January 1, 198…

SUBCHAPTER 22E - COOPERATIVE AGREEMENTS 10A NCAC 22E .0101 department of ENVIRONMENT AND NATURAL RESOURCES History Note: Authority G.S. 108A-25(b); 143B-10; Eff. February 1, 1976; Readopted Eff. October 31, 1977; Amended Eff. August 1, 1990; Expired Eff. September 1, 2015 pursuan…

SUBCHAPTER 22F - PROGRAM INTEGRITY SECTION .0100 - GENERAL 10A NCAC 22F .0101 SCOPE This Subchapter shall provide methods and procedures to ensure the integrity of the Medicaid program. Nothing in these procedures is intended, nor shall be construed, to grant any provider any rig…

10A NCAC 22F .0102 ORGANIZATION The North Carolina Department of Health and Human Services, Division of Health Benefits shall perform the duties required by this Subchapter. The Department or Division may enter into contracts with other persons for the purpose of performing these…

10A NCAC 22F .0103 FUNCTIONS (a) The Division shall develop, implement and maintain methods and procedures for preventing, detecting, investigating, reviewing, hearing, referring, reporting, and disposing of cases involving fraud, abuse, error, overutilization or the use of medic…

10A NCAC 22F .0104 PREVENTION (a) Provider Education. Upon the request of a provider, the Division may conduct on-site educational visits to assist a provider in complying with requirements of the Medicaid Program. (b) Provider Manuals. The Division shall prepare and make availab…

10a NCAC 22F .0105 DETECTION History Note: Authority G.S. 108A-25(b); 108A-63; 108A-64; 42 C.F.R. Part 455; 42 C.F.R. 455.12–23; Eff. May 1, 1984; Repealed Eff. July 1, 2018.

10a NCAC 22F .0106 CONFIDENTIALITY All investigations by the Division concerning allegations of provider fraud, abuse, over-utilization, or inadequate quality of care shall be confidential, and the information contained in the files of such investigations shall be confidential, e…

10a NCAC 22F .0107 RECORD RETENTION All Title XIX and Title XXI providers shall keep and maintain all Medicaid and NC Health Choice financial, medical, or other records necessary to disclose the nature and extent of services furnished to Medicaid and NC Health Choice recipients a…

SECTION .0200 - PROVIDER FRAUD AND PHYSICAL ABUSE OF RECIPIENTS 10A NCAC 22F .0201 DEFINITION OF PROVIDER FRAUD History Note: Authority G.S. 108A-25(b); 108A-63; 150B-21.6; 42 U.S.C. 1396(b) et seq.; 42 C.F.R. Part 455; Eff. April 15, 1977; Readopted Eff. October 31, 1977; Amende…

10a NCAC 22F .0202 INVESTIGATION (a) The Division shall conduct a preliminary investigation of all complaints received or allegations of fraud, waste, abuse, error, or practices not conforming to state and federal Medicaid laws and regulations, clinical coverage policies, or the …

10a NCAC 22F .0203 REFERRAL TO LAW ENFORCEMENT AGENCY The Division shall refer credible allegations of provider fraud, defined as provided by 42 C.F.R. 455.2, which is adopted and incorporated by reference with subsequent changes or amendments and available free of charge at http…

SECTION .0300 - PROVIDER ABUSE 10A NCAC 22f .0301 DEFINITION OF program ABUSE by providers Program abuse by providers as used in this Chapter consists of incidents, services, or practices inconsistent with accepted fiscal or medical practices which cause financial loss to the Med…

10A NCAC 22F .0302 INVESTIGATION (a) Fraud, waste, abuse, error, or practices not conforming to state and federal Medicaid laws and regulations, clinical coverage policies, or the Medicaid State Plan shall be investigated according to the provisions of Rule .0202 of this Subchapt…

section .0400 – agency reconsideration review 10A NCAC 22F .0401 PURPOSE History Note: Authority G.S. 108A-25(b); 42 C.F.R. 456; Eff. December 1, 1982; Transferred and Recodified from 10 NCAC 26I .0201 Eff. July 1, 1995; Pursuant to G.S. 150B-21.3A, rule is necessary without subs…

10A NCAC 22F .0402 RECONSIDERATION REVIEW FOR PROGRAM ABUSE (a) The Division shall notify the provider in writing by certified mail of the tentative decision made pursuant to Rule .0302 of this subchapter and the opportunity for a reconsideration of the tentative decision. (b) Th…

10A NCAC 22F .0403 PROCESS History Note: Authority G.S. 108A-25(b); 42 C.F.R. 456; Eff. December 1, 1982; Amended Eff. January 1, 1988; January 1, 1986; Transferred and Recodified from 10 NCAC 26I .0202 Eff. July 1, 1995; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A…

section .0600 – administrative sanctions and recoupment 10A NCAC 22F .0601 RECOUPMENT (a) The ­Division shall seek full restitution of improper payments, as defined by 42 C.F.R. 431.958, which is adopted and incorporated by reference with subsequent changes or amendments and avai…

10A NCAC 22F .0602 ADMINISTRATIVE ACTIONS (a) The following types of administrative actions may be imposed in any particular order by the Division in instances of program abuse by providers: (1) warning letters for instances of abuse that can be settled by issuing a warning to ce…

10A NCAC 22F .0603 PROVIDER LOCK-OUT (a) The Division may suspend the provider, based on the factors set out in Rule .0602(b) of this Subchapter, from participating in the Medicaid program, provided that the Division meets the requirements of 42 C.F.R. 431.54(f), which is adopted…

10A NCAC 22F .0604 WITHHOLDING OF MEDICAID PAYMENTS History Note: Authority G.S. 108A-25(b); 108A-54; 108A-54.1B; 108C-5; 150B-21.6; 42 C.F.R. Part 431; 42 C.F.R. 455.23; Eff. May 1, 1984; Amended Eff. December 1, 1995; Repealed Eff. September 1, 2018.

10A NCAC 22F .0605 TERMINATION History Note: Authority G.S. 108A-25(b); 42 C.F.R. Part 431; 42 C.F.R. Part 455; Eff. May 1, 1984; Repealed Eff. July 1, 2018.

10A NCAC 22F .0606 TECHNIQUE FOR PROJECTING MEDICAID OVERPAYMENTS History Note: Authority G.S. 108A-25(b); 108A-54; 108A-63; 42 C.F.R. Part 455, Subpart F; Eff. October 1, 1987; Temporary Amendment Eff. November 8, 1996; Amended Eff. August 1, 1998; Repealed Eff. July 1, 2018.

SECTION .0700 – recipient fraud and abuse 10A NCAC 22F .0701 DEFINITION OF FRAUD AND ABUSE (a) For purposes of this Section the word "person" includes any natural person, association, consortium, corporation, body politic, partnership, or other group, entity or organization. (b) …

10a NCAC 22F .0702 GENERAL The Division will establish a statewide program for the prevention, detection, investigation, referral, prosecution, recoupment of overpayments, and reporting of fraud, abuse, and overutilization due to recipient aberrant practices. The program will be …

10A NCAC 22F .0703 WARNING NOTIFICATION History Note: Authority G.S. 108A-25(b); 108A-64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456; Eff. May 1, 1984; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22F .0704 RECIPIENT MANAGEMENT LOCK-IN SYSTEM (a) The Division shall have methods and procedures for the control of recipient overutilization of Medicaid benefits. These methods and procedures shall include Lock-In of a recipient, shown to be an overutilizer, to specifie…

10A NCAC 22F .0705 OVERUTILIZATION SURVEILLANCE (SUR INDICATOR) History Note: Authority G.S. 108A-25(b); 108A-64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456; Eff. May 1, 1984; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22F .0706 RECOUPMENT OF RECIPIENT OVERPAYMENTS History Note: Authority G.S. 108A-25(b); 108A-64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456; Eff. May 1, 1984; Readopted Eff. July 1, 2018; Amended Eff. March 1, 2020; Expired Eff. September 1, 2025 pursuant…

10A NCAC 22F .0707 REPORTS AND REVIEWS History Note: Authority G.S. 108A-25(b); 108A-64; 42 C.F.R. Part 431; 42 C.F.R. Part 455; 42 C.F.R. Part 456; Eff. May 1, 1984; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

SUBCHAPTER 22g – REIMBURSEMENT PLANS SECTION .0100 – REIMBURSEMENT FOR NURSING FACILITY SERVICES 10A NCAC 22G .0101 REIMBURSEMENT PRINCIPLES History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C; Eff. January 1, 1978; Amende…

10A NCAC 22G .0102 RATE SETTING METHODS History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; 29 C.F.R. 1910, Subpart Z; 42 C.F.R. 447, Subpart C; S.L. 1991, c. 689, s. 95; Eff. January 1, 1978; Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on J…

10A NCAC 22G .0103 REASONABLE AND NON-ALLOWABLE COSTS History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C; Eff. January 1, 1978; Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 19…

10a NCAC 22G .0104 COST REPORTING: AUDITING History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447, Subpart C; Eff. January 1, 1978; Amended Eff. March 22, 1978; Emergency Amendment [(a), (h)] Eff. April 1, 1978 for a period of 120 days to expire on July 30, 197…

10A NCAC 22G .0105 case-mix index calculation History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S. L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C; Eff. January 1, 1978; Amended Eff. March 25, 1980; Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Ex…

10A NCAC 22G .0106 RECONSIDERATION REVIEWS History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985, c. 479, s. 86; 42 C.F.R. 447, Subpart C; Eff. January 1, 1978; Temporary Amendment Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, 1985; Amended…

10a NCAC 22G .0107 PAYMENT ASSURANCE History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; S.L. 1985, c. 479, s. 86; Section 95 of Chapter 689, 1991 Session Laws; 42 C.F.R. 447, Subpart C; Temporary Rule Eff. October 1, 1984 for a Period of 120 Days to Expire on January 28, …

10A NCAC 22G .0108 REIMBURSEMENT METHODS FOR STATE-OPERATED FACILITIES The Division's reimbursement methodology is set forth in the Medicaid State Plan. Any payments in excess of costs shall be refunded to the Division. Any costs in excess of payments shall be paid to the provide…

10A NCAC 22G .0109 NURSING HOME PROVIDER ASSESSMENT (a) In accordance with 42 USC 1396b(w) and 42 CFR, Part 433, Subpart B, which are adopted and incorporated by reference with subsequent changes or amendments; and consistent with the CMS Federal Waiver approved April 5, 2004 wit…

10A NCAC 22G .0110 DEFINITIONS "Public nursing facility", as used in 10A NCAC 22G, means any nursing facility that is: (1) Owned or operated by the State or any department or instrumentality of the State or by county, city, hospital district, or hospital authority; or (2) Is oper…

section .0200 – hospital inpatient reimbursement plan 10A NCAC 22G .0201 REIMBURSEMENT PRINCIPLES History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447, Subpart C; Eff. February 1, 1995; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22G .0202 DRG RATE SETTING METHODOLOGY History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447, Subpart C; Eff. March 1, 1995; Temporary Amendment Eff. January 22, 1998; Amended Eff. April 1, 1999; Temporary Amendment Eff. November 9, 2001; Temporary Ame…

10A ncac 22G .0203 EXCEPTIONS TO DRG REIMBURSEMENT History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55(c); 42 C.F.R. 447, Subpart C; 42 C.F.R. 447.321; Eff. February 1, 1995; Temporary Amendment Eff. September 15, 1995, for a period of 180 days or until the permanent rule b…

10A NCAC 22G .0204 DISPROPORTIONATE SHARE HOSPITALS (DSH) History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447, Subpart C; Eff. February 1, 1995; Amended Eff. July 1, 1995; Temporary Amendment Eff. September 15, 1995, for a period of 180 days or until the perm…

10A NCAC 22G .0205 OUT OF STATE HOSPITALS History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447, Subpart C; Eff. February 1, 1995; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A ncac 22G .0206 SPECIAL SITUATION History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447 Subpart C; Eff. February 1, 1995; Temporary Amendment Eff. December 10, 2001; Temporary Amendment Expired September 29, 2002; Amended Eff. August 1, 2004; Expired Eff. Se…

10A NCAC 22G .0207 COST REPORTING AND AUDITS History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447, Subpart C; Eff. February 1, 1995; Expired Eff. September 1, 2015 pursuant to G.S. 150B-21.3A.

10A NCAC 22G .0208 ADMINISTRATIVE RECONSIDERATION REVIEWS History Note: Authority G.S. 108A-25(b); 108A-54; 108A-55; 42 C.F.R. 447, Subpart C; Eff. February 1, 1995; Repealed Eff. July 1, 2018.