The HCA strives to work together with our providers and provide education about program integrity.
- Provider resources (training)
- Programs and services
- Provider enrollment
- Washington Apple Health (Medicaid) providers
- Apple Health Preferred Drug List (PDL)
- Sign up for Provider Alerts (view past Provider Notices)
Frequently asked questions (FAQs)
- Desk audits and reviews
- Onsite audits
- Data mining
- Site visits
- CMS Medicaid Integrity Contractor (MIC) audits
- CMS Payment Error Rate Measurement (PERM) reviews
- Health & Human Services (HHS) Office of Inspector General (OIG) audits
- Medicaid Recovery Audit Contractor (RAC) audits
- Providers will typically receive written notification by certified mail from the Section of Program Integrity (PI)
- Providers may receive an overpayment notice if an algorithm or data review identifies overpayments.
- As authorized by WAC 182-502A, unannounced visits may occur.
- 100 percent review of a provider's claims for a specific period
- Random stratified or non-stratified sample of claims for a specific time period
- Criteria-driven selection of specific claims for a specific time period
Providers must retain documentation that supports the services billed to the HCA. PI may request the following types of information and records; please note that this is not an all-inclusive listing:
- Appointment books/patient sign-in sheets.
- Coding summary.
- Complete hospital medical records.
- Core Provider Agreement.
- Credit balance reports.
- Dental x-ray films.
- Diagnostic test results (e.g. lab reports, radiology/nuclear medicine reports, etc.).
- Durable & non-durable medical equipment/product delivery documents.
- Financial reports/accounting/billing records, charge masters, service level descriptions.
- Medication administration records/sheets.
- Office/facility policies/employment records.
- Office visit/hospital visit notes.
- Ownership agreement/business licenses and professional staff licenses/certificates.
- Patient care plans.
- Physician/practitioner orders.
- Prescription records.
- Proof of delivery documents.
- Surgical, recovery and anesthesia records.
- Transfer records/referral documents.
- Treatment records.
Providers must maintain appropriate documentation in the client's medical or health care service records for 6 years.
Please see WAC 182-502-0020.
- Provide a workspace or room, with table and chairs and adequate electrical outlets for audit equipment.
- Have key office staff available during the audit for the audit team to interview.
- If medical records are requested in advance, please have records in alphabetical order placed in the designated workspace for the auditors.
- Have copies of current business license(s) and professional healthcare licenses of all pertinent staff available for the auditors.
- A provider may informally dispute a draft audit report or preliminary review notice within 30 days from receipt of the report or notice. See WAC 182-502A-0801.
- A provider may request an administrative hearing to formally appeal a final audit report or notice of improper payment within 28 days from receipt of the report or notice. See WAC 182-502A-0901 and RCW 41.05A.170.
- A provider may informally dispute and formally appeal an algorithm overpayment notice. To formally appeal, a provider must request an administrative hearing within 28 days from receipt of overpayment notice. There is not a separate time period to submit an informal dispute. Therefore it must also be received within 28 days of receipt of an algorithm overpayment notice. See WAC 182-502-0230 and RCW 41.05A.170.
- When an audit or review is in the draft or preliminary state, a provider may contact the auditor to request an extension.
- If the provider has received a final audit report, notice of improper payment or overpayment notice, no extension is allowed. See RCW 41.05A.170.
- Department of Social and Health Services (DSHS) Office of Financial Recovery
- Department of Health
- Attorney General's Office
- Medicaid Fraud Control Unit
- Other stakeholders as appropriate
- WAC 182-502A-0701 allows referral for disciplinary or criminal action if warranted