1. GACCP SPRING TRAINING Presentation to: GACCP NOW / COMP Providers
Presented by: Marcia Stanford, Human Services Program Auditor, DCH-OIG, Program Integrity
Date:

2. Mission The Georgia Department of Community Health
We will provide access to affordable, quality health care to Georgians through effective planning, purchasing and oversight.
We are dedicated to A Healthy Georgia.

3. (use as needed; feel free to delete)
Corrective Action Plans
Overpayment Recovery
Exceptional Rate
Title or Chapter Slide
(use as needed; feel free to delete)

4. Information in The Manuals Is Important
ALWAYS IMPORTANT
Read Your Manuals
Information in The Manuals Is Important
Nothing Will Replace Your Reading The Manuals

5. Provider Manual Website https://www.mmis.georgia.gov
Click on ”Provider Information”
Click on “Provider manual” in drop down list
Scroll down midway on page to “Provider manual” (92 rows returned)
Locate desired manual on list and “left” click on manual title
Click “edit” on the toolbar
Select “Find” on the drop down list
Type in subject you desire to search for in manual – example “Medications”
Click on arrow next to “find” box to scroll through manual to locate the subject you desire to research.
You can instantly locate any topic you want to research in the provider manuals very quickly by using “Edit” and “Find” buttons.

6. The Information in the Manuals is Essential
Always Important
Read Your Manuals
The Information in the Manuals is Essential

7. Monitoring/Corrective Action Plan (CAP)
Corrective Action Plan as noted in Section 1107 of the Part II POLICIES AND PROCEDURES FOR COMPREHENSIVE SUPPORTS and NEW OPTIONS WAIVER PROGRAM
Monitoring/Corrective Action Plan (CAP)
When DCH utilization reviews result in deficiencies, the provide must submit a CAP to the Department within fifteen (15) calendar days of the date of utilization review reports
Failure to comply with the request for a CAP may result in adverse action, including suspension of referrals or termination from the program

8. Corrective Action Plans
Corrective Action Plan as noted in Section of the PART I POLICIES AND PROCEDURES FOR MEDICAID / PEACHCARE FOR KIDS
Corrective Action Plans
The Division can require the submission of a Corrective Action Plan
The Division reserves the right to determine which providers will be subject to this requirement
Corrective Action Plans must:
Specific
Include provisions aimed toward deficiency correction
Indicate reasonable completion dates

9. Corrective Action Plans (CAP) must be:
Corrective Action Plan as noted in Section of the PART I POLICIES AND PROCEDURES FOR MEDICAID / PEACHCARE FOR KIDS
Corrective Action Plans (CAP) must be:
Specific
Include provisions aimed toward deficiency correction
Indicate reasonable completion dates
Fully describe the methodology used to accomplish complete and permanent corrective action and
Describe methods for ensuring full compliance with the corrective action plan
Corrective Action Plan are subject to review by the Division to ensure compliance

10. Corrective Action Plan as noted in Section 402
Corrective Action Plan as noted in Section of the PART I POLICIES AND PROCEDURES FOR MEDICAID / PEACHCARE FOR KIDS
Violation of the CAP includes the failure to implement as directed will subject the provider to
Failure to implement as directed will subject the provider to further adverse action including
Further monetary recoupment
termination
Adverse action may be based upon both the initial utilization review and the CAP
Termination – Section B…Termination shall be for a minimum of one (1) year .

11. Overpayment Recovery as noted in Section 402
Overpayment Recovery as noted in Section of the PART I POLICIES AND PROCEDURES FOR MEDICAID / PEACHCARE FOR KIDS
Overpayment Recovery
A refund of amounts identified as overpayments by the Division following Utilization Review are due within thirty (30) days after the date of a formal Request for Refund unless the provider has requested and been granted an extension by the Director of Program Integrity. A request for an Administrative Law Hearing will not alter this deadline

12. Overpayment Recovery as noted in Section 402
Overpayment Recovery as noted in Section of the PART I POLICIES AND PROCEDURES FOR MEDICAID / PEACHCARE FOR KIDS
If no refund has been received by the Division within the applicable timeframe
Other appropriate recovery proceedings will ensue without separate notice to the provider
Should recoupment procedures become necessary
Claims submitted will be reduced by 100%, or
Such other amount as the Division may elect, until the amount owed is recovered
The Division may seek other means of recovery

13. Payment shall be for the entire amount of the overpayment
Overpayment Recovery as noted in Section of the PART I POLICIES AND PROCEDURES FOR MEDICAID / PEACHCARE FOR KIDS
Payment shall be for the entire amount of the overpayment
A payment for less than the entire amount of the overpayment shall be treated as an installment payment
This action shall not stay the thirty (30) day time period noted above.

14. Administrative Review Section 505 of the PART I POLICIES AND PROCEDURES FOR MEDICAID / PEACHCARE FOR KIDS
Administrative Review is offered to any provider against whom it proposes to take an adverse action or denial of payment (with the exception of Section 404) unless otherwise authorized by law to take such action without Administrative Review. Administrative Review shall be completed, if not waived by the provider.
A written request for Administrative Review must be received by the Department within thirty (30) days

15. Administrative Review Section 505 of the PART I POLICIES AND PROCEDURES FOR MEDICAID / PEACHCARE FOR KIDS
A written request for Administrative Review must be received by the Department within thirty (30) days of the date the notification of the proposed adverse action was mailed to the provider.
The request must include all grounds for Administrative Review
Must be accompanied by all supporting documentation and explanation that the provider wishes the Division to consider

16. The request must include all grounds for Administrative Review
Administrative Review Section 505 of the PART I POLICIES AND PROCEDURES FOR MEDICAID / PEACHCARE FOR KIDS
The request must include all grounds for Administrative Review
Must be accompanied by all supporting documentation and explanation that the provider wishes the Division to consider
Letters requesting Administrative Review that are not accompanied by supporting documentation will not be accepted or considered.

17. Administrative Review / Administrative Law Hearing Section 505 and 506 of the PART I POLICIES AND PROCEDURES FOR MEDICAID / PEACHCARE FOR KIDS
Failure to comply with the requirements of Administrative Review, including the failure to submit all necessary documentation within thirty (30) days, shall constitute a waiver of any and all further appeal rights, including the right to a hearing
Administrative Law Hearing issues are limited to those issues that have been through the Administrative Review process

18. Administrative Review / Administrative Law Hearing Section 505 and 506 of the PART I POLICIES AND PROCEDURES FOR MEDICAID / PEACHCARE FOR KIDS
A Request for Hearing must be in writing and received by the Division within fifteen (15) business days after the date the provider received the decision of the Division that is the basis for the appeal

19. Exceptional Rate
There must be an Exceptional Rate Approval letter in the participant’s record
The provider must include documentation of all services as stated in the Exceptional Rate Approval letter

20. Information in The Manuals Is Important
ALWAYS IMPORTANT
Read Your Manuals
Information in The Manuals Is Important
Nothing Will Replace Your Reading The Manuals