The vendor is required to provide for desk and on-site audits of services delivered and claims billed by Medicaid-enrolled providers to Medicaid-eligible clients.
- Medical assistance programs during fiscal year 2023.
- The audits include ensuring provider compliance with state and federal policies, regulations and statutes, recovering overpayments, supporting the investigation and prosecution of violations of criminal statutes and protecting the Medicaid program from inappropriate expenditures resulting from fraud, waste, abuse or misuse.
- Medical assistance programs to bill for services provided to program members.
- The on-site audits and desk audits are utilized to determine:
• The services billed by providers on claims documents were actually provided to Medicaid recipients who were eligible at the time that services were delivered; 
• The services, procedure codes, and number of units for which claims were submitted reconcile with the recipient’s medical chart record of the services rendered, and the services were medically necessary; 
• That the stop and start times are documented for all time-based codes; 
• That the diagnoses recorded on the claim forms reconcile with the medical charts; 
• That the provider records substantiate that the services were rendered on the dates for which the claims were submitted; 
• That the provider followed Medicaid rules and appropriately billed all third-party payers, applied proper co-payment and recipient cost-of-care as required; 
• That no duplicate billings and payments were made or received by the provider; 
• That no concurrent inpatient, nursing facility or other residential care billings exist with other Medicaid providers; 
• That the provider obtained appropriate authorization for services as applicable; 
• That billings and payments did not exceed applicable service limits or 24 hours of service in one day; 
•  That the place of service code billed was accurate for the site at which the service was provided (inpatient hospital, office visit, etc.); 
• That Medicaid-eligible medical providers were enrolled with state Medicaid at the time of service; and complied with the requirement
• That the providers complied with their state Medicaid provider agreement to identify and quantify overpayments and to detect all possible violations of state and federal policies, regulations and criminal statutes.
- Budget of $6,275,000.00
- Contract Period/Term: 3 years
- Questions/Inquires Deadline: June 30, 2025