Section 29-5613. AUDIT AND REPORTING REQUIREMENTS

 

5613.1The managed care provider shall file a financial statement annually with the Department, which shall be certified by at least two (2) principal officers. The financial statement shall be filed with the Department not more than ninety (90) days after the close of the provider’s fiscal year.

 

5613.2The managed care provider shall have the financial statement described in §5613.1 audited by an independent certified public account.

 

5613.3The audited financial statement shall clearly indicate total expenses and revenues and specify the expenses and revenues attributable to eligible children enrolled in the managed care provider’s plan.

 

5613.4Upon the Department’s written request, the managed care provider shall permit and assist the federal government or its agents, or the Department in the inspection and audit of any financial records of the provider or its subcontractors. The provider agreement shall require that the provider’s and subcontractor’s records be available for inspection and audit by the Department.

 

5613.5Annual audit reports and records shall be retained by the managed care provider for at least a five (5) year period.

 

5613.6If any litigation, claim, negotiation, audit, or other action involving the records described in this section is initiated before the expiration of the five (5) year period, the records shall be retained until completion of the action and final resolution of all issues that arise from the litigation, claim, negotiation, audit, or other action, including any appeal and the expiration of any right of appeal, or until the end of the five (5) year period, whichever is later.

 

5613.7Each month, the managed care provider shall submit reports of program utilization, costs, and other information necessary to assess the provider’s performance. The Department shall describe the content and format of these reports.

 

5613.8Each quarter, the managed care provider shall submit a summary of program utilization in the format prescribed by the Department. This summary shall include the following information with respect to eligible children enrolled in the provider’s plan:

 

(a)Number of member-months in the quarter;

 

(b)Number of newly enrolled children;

 

(c)Number of children disenrolled;

 

(d)Number of inpatient admissions and inpatient days incurred;

 

(e)Number of physician visits provided;

 

(f)Number of out-of-plan referrals; and

 

(g)Number of emergency room encounters.

 

5613.9The managed care provider shall prepare semiannual summaries of financial performance under its Medicaid managed care provider agreement that describes the total clinical expenditures incurred and assigned contribution to overhead.

 

5613.10The quarterly utilization summary and semiannual financial summary shall be submitted to the Department not later than ninety (90) days after the close of the quarter or the six (6) month semi-annual review period.

 

source

Final Rulemaking published at 43 DCR 4833, 4851 (September 6, 1996).