Standard Review Process
- Provider is notified approximately 2 weeks in advance of the review.
- An entrance conference is held at the onset of the review, in person or telephonically.
- A preliminary review of the documentation available for review is conducted.
- An exit conference is held at the completion of the preliminary documentation review.
- A Preliminary Report is issued after DMAS approval. The Preliminary Report may include a Preliminary Claims List, a Preliminary Service Log and a Preliminary Discrepancies Letter.
- If discrepancies have been identified on the Preliminary Report, the Provider is afforded 30 days to respond to the Preliminary Report. This may include additional documentation and information in response to the preliminary discrepancies that have been identified on the report.
- The Provider's response to the Preliminary Report is then reviewed to determine if the additional documentation and information submitted resolves the discrepancies identified on the Preliminary Report.
- If discrepancies remain after review of the Provider's response to the Preliminary Report, an Overpayment Report is issued after DMAS approval. (If the Provider does not submit a response within 30 days of the Preliminary Report, an Overpayment Report will be issued after DMAS approval.) The Overpayment Report may include an Overpayment Claims List, an Overpayment Service Log and an Overpayment Letter.
- The Overpayment Letter includes information on the Provider's appeal rights, if the Provider disagrees with the findings within the Overpayment Report.