Colorado 2025 Regular Session

Colorado Senate Bill SB314 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		First Regular Session
2	2		Seventy-fifth General Assembly
3	3		STATE OF COLORADO
4		-	~~REREVISED~~
5		-	This Version Includes All Amendments
6		-	~~Adopted~~ in the Second House
	4	+	REVISED
	5	+	This Version Includes All Amendments Adopted
	6	+	on Second Reading in the Second House
7	7		LLS NO. 25-0717.01 Chelsea Princell x4335
8	8		SENATE BILL 25-314
9	9		Senate Committees House Committees
10	10		Appropriations Appropriations
11	11		A BILL FOR AN ACT
12	12		C
13	13		ONCERNING CHANGES TO TH E RECOVERY AUDIT CONTRACTOR101
14	14		PROGRAM, AND, IN CONNECTION THEREWITH , MAKING AND102
15	15		REDUCING AN APPROPRIATION .103
16	16		Bill Summary
17	17		(Note: This summary applies to this bill as introduced and does
18	18		not reflect any amendments that may be subsequently adopted. If this bill
19	19		passes third reading in the house of introduction, a bill summary that
20	20		applies to the reengrossed version of this bill will be available at
21	21		http://leg.colorado.gov/
22	22		.)
23	23		Joint Budget Committee. The bill allows the department of health
24	24		care policy and financing (state department) to contract with a recovery
25	25		audit contractor (RAC) vendor to conduct RAC audits of medicaid
26	26		providers (providers) on behalf of the state department.
27	27		RAC audits may only review claims that are no more than 3 years
28	28		HOUSE
29		-	3rd Reading Unamended
30		-	May 2, 2025
31		-	HOUSE
32	29		2nd Reading Unamended
33	30		May 1, 2025
34	31		SENATE
35	32		3rd Reading Unamended
36	33		April 30, 2025
37	34		SENATE
38	35		Amended 2nd Reading
39	36		April 29, 2025
40	37		SENATE SPONSORSHIP
41	38		Kirkmeyer and Bridges, Amabile, Catlin, Frizell, Lundeen, Mullica, Snyder
42	39		HOUSE SPONSORSHIP
43		-	Bird and Sirota, Taggart~~, Boesenecker, Brown, Lindstedt~~
	40	+	Bird and Sirota, Taggart
44	41		Shading denotes HOUSE amendment. Double underlining denotes SENATE amendment.
45	42		Capital letters or bold & italic numbers indicate new material to be added to existing law.
46	43		Dashes through the words or numbers indicate deletions from existing law. past the date of the expiration of the timely filing period. The bill allows
47	44		the state department to review claims that fall outside of this 3-year time
48	45		frame only if required by a federal audit.
49	46		The bill limits the number of audits a provider may undergo each
50	47		year and limits the number of medical records that can be requested for
51	48		a given audit.
52	49		If the state department identifies preliminary findings during the
53	50		RAC audit, the state department must send the provider a report detailing
54	51		the preliminary findings, the rationale for the preliminary findings, and
55	52		the methodology for how any overpayments were calculated and
56	53		determined.
57	54		The bill allows a provider that received preliminary findings
58	55		following a complex audit to request an exit conference to discuss the
59	56		preliminary findings with the state department in an effort to resolve the
60	57		concerns detailed in the preliminary findings prior to undergoing an
61	58		informal reconsideration of the preliminary findings.
62	59		The bill requires a provider to participate in an informal
63	60		reconsideration before filing a formal appeal regarding the state
64	61		department's findings during a RAC audit.
65	62		The bill, in the department of health care policy and financing for
66	63		medical and long-term care services for medical-eligible individuals
67	64		budget, decreases the cash funds appropriation from recoveries and
68	65		recoupments by $20,900,588 and the cash funds appropriation from the
69	66		recovery audit contractor recoveries cash fund is increased by
70	67		$20,900,588.
71	68		Be it enacted by the General Assembly of the State of Colorado:1
72	69		SECTION 1. In Colorado Revised Statutes, 25.5-4-301, amend2
73	70		(3.5)(c); repeal (3)(a)(IX); and add (3.3) as follows:3
74	71		25.5-4-301. Recoveries - overpayments - penalties - interest -4
75	72		adjustments - liens - review or audit procedures - cash fund - rules -5
76	73		definitions - repeal. (3) (a) A review or audit of a provider is subject to6
77	74		the following procedures:7
78	75		(IX) For audits conducted pursuant to 42 CFR 455.506, at least
79	76		8
80	77		quarterly, the state department shall publish on its website an audit9
81	78		activity report detailing current and recently completed audits and reviews10
82	79		and summaries of the findings of such audits and reviews, including the11
83	80		314-2- number and amounts of overpayments and underpayments found, the1
84	81		number and results of appeals, the amounts collected, and the error rates2
85	82		identified. At least quarterly, the state department shall conduct trainings3
86	83		for providers and hold stakeholder meetings regarding audits and reviews.4
87	84		In addition, when the state department enters into contracts pursuant to5
88	85		this subsection (3)(a), the state department shall publish on its website a6
89	86		copy of the contract, scope of work, and information regarding7
90	87		supervision of contractor deliverables.8
91	88		(3.3) (a) A
92	89		S USED IN THIS SUBSECTION (3.3), UNLESS THE CONTEXT9
93	90		OTHERWISE REQUIRES:10
94	91		(I) "A
95	92		UTOMATED AUDIT" MEANS A RAC AUDIT THAT REVIEWS A11
96	93		PROVIDER'S APPLICATION OF CODING RULES AND DOES NOT REQUIRE A12
97	94		PROVIDER TO SUBMIT MEDICAL RECORDS TO BE AUDITED .13
98	95		(II) "C
99	96		OMPLEX AUDIT" MEANS A RAC AUDIT THAT REQUIRES A14
100	97		PROVIDER TO SUBMIT MEDICAL RECORDS TO BE AUDITED , WHICH ARE15
101	98		INDIVIDUALLY REVIEWED BY A REPRESENTATIVE OF THE STATE16
102	99		DEPARTMENT OR THE STATE DEPARTMENT 'S RAC VENDOR.17
103	100		(III) "D
104	101		ENIAL RATE" MEANS THE PERCENTAGE OF REVIEWED18
105	102		CLAIMS ULTIMATELY DETERMINED TO INVOLVE IMPROPER PAYMENTS19
106	103		AFTER ALL ADMINISTRATIVE PROCESSES ARE COMPLETE , INCLUDING THE20
107	104		RESOLUTION OF AN APPEAL.21
108	105		(IV) "RAC
109	106		AUDIT" MEANS A RECOVERY AUDIT CONTRACTOR22
110	107		AUDIT CONDUCTED PURSUANT TO THE FEDERAL "SOCIAL SECURITY ACT",23
111	108		42
112	109		U.S.C. SEC. 1396a (a)(42)(B).24
113	110		(V) "RAC
114	111		VENDOR" MEANS A VENDOR WHO MEETS THE25
115	112		REQUIREMENTS OF 42 CFR 455.508 AND CONTRACTS WITH THE STATE26
116	113		DEPARTMENT TO PERFORM RECOVERY AUDIT CONTRACTOR AUDITS OF27
117	114		314
118	115		-3- PROVIDERS ON BEHALF OF THE STATE DEPARTMENT .1
119	116		(b) T
120	117		HE STATE DEPARTMENT MAY SOLICIT THE SERVICES OF A RAC2
121	118		VENDOR THR OUGH A CONTRACT ISSUED PURS UANT TO THE3
122	119		"P
123	120		ROCUREMENT CODE", ARTICLES 101 TO 112 OF TITLE 24, AND PURSUANT4
124	121		TO THE FEDERAL REQUIREMENTS DETAILED IN 42 CFR 455.508, FOR THE5
125	122		PURPOSE OF CONDUCTING RAC AUDITS OF PROVIDERS TO IDENTIFY6
126	123		POSSIBLE MEDICAID OVERPAYMENTS AND UNDERPAYMENTS .7
127	124		(c) (I) T
128	125		HE CONTRACT DESCRIBED IN SUBSECTION (3.3)(b) OF THIS8
129	126		SECTION MUST STATE THAT THE RAC VENDOR'S COMPENSATION IS9
130	127		CONTINGENT UPON THE AMOUNT OF OVERPAYMENTS THE STATE RECOVERS10
131	128		FROM A PROVIDER. AT THE EXPIRATION OF THE CURRENT CONTRACT11
132	129		BETWEEN THE STATE DEPARTMENT AND THE RAC VENDOR, THE STATE12
133	130		DEPARTMENT SHALL ESTABLISH CONTINGENCY FEE RATES BASED ON13
134	131		MARKET RATES DETERMINED BY THE RESULTS OF A COMPETITIVE14
135	132		PROCUREMENT PROCESS AND MAY NEGOTIATE LOWER RATES AS THE15
136	133		MARKET PROVIDES, WITH CONTINGENCY RATES NOT TO EXCEED SIXTEEN16
137	134		PERCENT OF RECOVERED PAYMENTS . THE STATE DEPARTMENT SHALL17
138	135		ENSURE THAT THE CONTINGENCY FEE REQUIREMENTS ARE ADHERED TO18
139	136		THROUGH EFFECTIVE MONITORING AND ENFORCEMENT OF THE RAC19
140	137		VENDOR'S PERFORMANCE. FOR CONTRACTS ENTERED INTO AFTER THE20
141	138		EXPIRATION OF THE CONTRACT THAT ESTABLISHED CONTINGENCY FEE21
142	139		RATES FOR RAC VENDOR PAYMENTS, THE STATE DEPARTMENT SHALL22
143	140		STRUCTURE THE RAC VENDOR COMPENSATION BASED ON A TIERED23
144	141		PAYMENT SYSTEM THAT CORRESPONDS TO THE REQUIRED WORK UNLESS24
145	142		DOING SO CONFLICTS WITH FEDERAL DIRECTIVES IN MEDICAID GUIDANCE25
146	143		PURSUANT TO 42 CFR 455, SUBPART F, OR RESULTS IN AN UNFAVORABLE26
147	144		IMPACT TO THE STATE'S GENERAL FUND.27
148	145		314
149	146		-4- (II) WHEN THE STATE DEPARTMENT ENTERS INTO A CONTRACT1
150	147		PURSUANT TO SUBSECTION (3.3)(b) OF THIS SECTION, THE STATE2
151	148		DEPARTMENT MUST PUBLISH ON ITS WEBSITE A COPY OF THE CONTRACT ,3
152	149		SCOPE OF THE WORK, AND INFORMATION REGARDING SUPERVISION OF4
153	150		CONTRACTOR DELIVERABLES .5
154	151		(III) T
155	152		HE CONTRACT DESCRIBED IN SUBSECTION (3.3)(b) OF THIS6
156	153		SECTION MUST REQUIRE THE RAC VENDOR TO:7
157	154		(A) C
158	155		ONDUCT INFORMAL CONFERENCES OR PHONE CALLS WITH8
159	156		PROVIDERS OR PROVIDER ASSOCIATIONS TO DISCUSS THE RAC PROGRAM,9
160	157		PROCESSES, AND FINDINGS;10
161	158		(B) C
162	159		ONDUCT PROVIDER OUTREACH AND EDUCATION ACTIVITIES ,11
163	160		INCLUDING NOTIFYING PROVIDERS OF AUDIT POLICIES , PROTOCOLS, AND12
164	161		COMMON BILLING ERRORS;13
165	162		(C) R
166	163		ESPOND TO PROVIDER QUESTIONS AND REQUESTS FOR14
167	164		INFORMATION WITHIN TWO BUSINESS DAYS AFTER RECEIVING THE15
168	165		QUESTION OR REQUEST FOR INFORMATION ;16
169	166		(D) R
170	167		ETURN, WITHIN THIRTY DAYS, THE CONTINGENCY FEE17
171	168		ASSOCIATED WITH INACCURATE AUDIT SCENARIOS THAT RESULTED IN18
172	169		PROVIDER REFUNDS AS PRESCRIBED BY THE STATE DEPARTMENT ; AND19
173	170		(E) P
174	171		ROVIDE PRELIMINARY RAC AUDIT FINDINGS TO A PROVIDER
175	172		20
176	173		WITHIN A REASONABLE PERIOD FOLLOWING RECEIPT OF ANY REQUESTED21
177	174		MEDICAL RECORDS, AS DETERMINED BY THE STATE DEPARTMENT IN22
178	175		COLLABORATION WITH THE PROVIDER ADVISORY GROUP , CREATED IN23
179	176		SUBSECTION (3.5)(c)(I) OF THIS SECTION.24
180	177		(d) T
181	178		HE RAC CONTRACT DESCRIBED IN SUBSECTION (3.3)(b) OF25
182	179		THIS SECTION MAY INCLUDE AN OPTION TO PAY THE RAC VENDOR TO26
183	180		IDENTIFY UNDERPAYMENTS FOR CONSIDERATION IN FUTURE STATE27
184	181		314
185	182		-5- DEPARTMENT BUDGET REQUESTS .1
186	183		(e) (I) T
187	184		HE STATE DEPARTMENT SHALL IMPLEMENT A PROCESS TO2
188	185		VERIFY THAT THE RAC VENDOR'S STAFF WHO MAKE CLINICAL RAC AUDIT3
189	186		FINDINGS ARE APPROPRIATELY LICENSED PURSUANT TO INDUSTRY4
190	187		STANDARDS AND FEDERAL REQUIREMENTS , INCLUDING THAT THE RAC5
191	188		VENDOR HIRE QUALIFIED CODERS AND THAT THE RAC VENDOR'S STAFF6
192	189		WHO MAKE BILLING RAC AUDIT FINDINGS HAVE KNOWLEDGE OF MEDICAID7
193	190		BILLING AND CODING RULES AND GUIDANCE ADOPTED BY THE STATE8
194	191		DEPARTMENT.9
195	192		(II) T
196	193		HE STATE DEPARTMENT MUST ENSURE THAT QUALIFIED10
197	194		CODERS HAVE RELEVANT CREDENTIALS FOR THE TYPE OF MEDICAL11
198	195		SERVICES BEING REVIEWED, IN ACCORDANCE WITH INDUSTRY STANDARDS .12
199	196		(III) A
200	197		NY COMPLEX AUDIT THAT REQUIRES A REVIEW OF MEDICAL13
201	198		RECORDS MUST BE CONDUCTED BY LICENSED CLINICAL STAFF WITH14
202	199		TRAINING AND COMPETENCY IN THE SPECIFIC TYPE OF COMPLEX AUDIT15
203	200		BEING CONDUCTED, IN ACCORDANCE WITH INDUSTRY STANDARDS .16
204	201		P
205	202		ROVIDERS MUST MAKE ALL RELEVANT MEDICAL RECORDS AND17
206	203		INFORMATION RELATED TO CLAIMS REVIEWED DURING THE COMPLEX18
207	204		AUDIT AVAILABLE TO THE RAC VENDOR WITHIN THE TIME LIMITS19
208	205		SPECIFIED IN THE INITIAL MEDICAL RECORDS REQUEST .20
209	206		(IV) T
210	207		HE STATE DEPARTMENT SHALL FULLY INFORM THE RAC21
211	208		VENDOR OF ANY CHANGES TO THE STATE BILLING ST ANDARDS AND ENSURE22
212	209		THAT THE VENDOR ONLY APPLIES BILLING STANDARDS THAT WERE IN23
213	210		EFFECT AT THE SPECIFIED DATE OF SERVICE. THE STATE DEPARTMENT IS24
214	211		RESPONSIBLE FOR MONITORING COMPLIANCE WITH THIS REQUIREMENT25
215	212		AND TAKING APPROPRIATE ACTION TO ENSURE THE RAC VENDOR'S26
216	213		COMPLIANCE.27
217	214		314
218	215		-6- (V) THE STATE DEPARTMENT SHALL ENSURE THAT THE RAC1
219	216		VENDOR COMPLIES WITH THE CONTRACT REQUIREMENTS DESCRIBED IN2
220	217		SUBSECTION (3.3)(b) OF THIS SECTION AND CONDUCTS RAC AUDITS IN A3
221	218		FAIR AND CONSISTENT MANNER .4
222	219		(VI) T
223	220		HE STATE DEPARTMENT SHALL ENSURE THAT THE RAC5
224	221		VENDOR INCORPORATES INTO EACH AUDIT SCENARIO , WHETHER AN6
225	222		AUTOMATED AUDIT OR A COMPLEX AUDIT , THE FOLLOWING INFORMATION:7
226	223		(A) F
227	224		EDERAL STATUTES AND BILLING RULES AND STANDARDS8
228	225		THAT ARE APPLICABLE TO THE SPECIFIC PROVIDER DURING THE SPECIFIED9
229	226		DATES OF SERVICE FOR EACH AUDIT;10
230	227		(B) S
231	228		TATE STATUTES, BILLING RULES AND STANDARDS , AND11
232	229		POLICIES AS DOCUMENTED IN THE STATE DEPARTMENT 'S PROVIDER BILLING12
233	230		MANUALS AND PROVIDER BULLETINS , AS WELL AS IN PROGRAM GUIDANCE13
234	231		AND DIRECTIVES EFFECTIVE FOR THE SPECIFIC PROVIDER DURING THE14
235	232		SPECIFIED DATES OF SERVICE FOR EACH AUDIT; AND15
236	233		(C) I
237	234		NPUT FROM THE STATE DEPARTMENT 'S RAC STAFF AND16
238	235		MEDICAL DIRECTOR, AS WELL AS ANY OTHER NECESSARY STATE17
239	236		DEPARTMENT STAFF BASED ON THE STAFF 'S OR MEDICAL DIRECTOR'S18
240	237		REVIEW OF THE AUDIT SCENARIO.19
241	238		(VII) W
242	239		HEN AUDITING CLAIMS TO MAKE RAC AUDIT FINDINGS,20
243	240		THE STATE DEPARTMENT MUST ENSURE THAT THE RAC VENDOR FOLLOWS21
244	241		ALL RELEVANT AND APPROPRIATE FEDERAL BILLING GUIDELINES ,22
245	242		REQUIREMENTS SET BY THE MEDICAID BILLING MANUAL , STANDARD23
246	243		CLINICAL GUIDELINES, AND ANY OTHER APPLICABLE STATE OR FEDERAL24
247	244		RULES AND REGULATIONS.25
248	245		(f) T
249	246		HE STATE DEPARTMENT SHALL COMPREHENSIVELY REVIEW26
250	247		ALL AUDIT TYPES PROPOSED BY THE RAC VENDOR AND MUST APPROVE ,27
251	248		314
252	249		-7- ADJUST, OR REJECT EACH AUDIT TYPE BEFORE THE RAC VENDOR1
253	250		CONDUCTS THE RAC AUDIT. WITHIN EIGHTEEN MONTHS OF THE ROLLOUT2
254	251		OF A NEW AUDIT, IF THE STATE DEPARTMENT, IN COLLABORATION WITH3
255	252		PROVIDERS AND THE PROVIDER ADVISORY GROUP CREATED IN SUBSECTION4
256	253		(3.5)
257	254		OF THIS SECTION, DETERMINES THAT THE AUDIT IS INACCURATE, THE5
258	255		STATE DEPARTMENT MUST REFUND PROVIDERS WHO SUBMITTED6
259	256		REPAYMENTS BASED ON INACCURATE AUDIT FINDINGS AND REQUIRE THE7
260	257		RAC
261	258		VENDOR TO RETURN THE CONTINGENCY FEE ASSOCIATED WITH THE8
262	259		PAYMENTS WITHIN THIRTY DAYS .9
263	260		(g) T
264	261		HE STATE DEPARTMENT SHALL REGULARLY REVIEW ACTIVE10
265	262		RAC
266	263		AUDITS TO ENSURE COMPLIANCE WITH FEDERAL AND STATE11
267	264		REGULATION CHANGES AND POLICY UPDATES AND DISCONTINUE A RAC12
268	265		AUDIT IF AND WHEN APPROPRIATE DUE TO A CHANGE IN FEDERAL OR STATE13
269	266		REGULATION OR POLICY UPDATES .14
270	267		(h) C
271	268		ONSISTENT WITH 42 CFR 455.508 (f), RAC AUDITS AND15
272	269		REVIEWS CONDUCTED PURSUANT TO THIS SECTION MUST NOT REVIEW16
273	270		CLAIMS MORE THAN THREE YEARS AFTER THE EXPIRATION OF THE TIMELY17
274	271		FILING PERIOD. THE STATE DEPARTMENT MAY CONDUCT A RAC AUDIT FOR18
275	272		A CLAIM FILED MORE THAN THREE YEARS AFTER THE EXPIRATION OF THE19
276	273		TIMELY FILING PERIOD IF REQUIRED BY A FEDERAL AUDIT THAT WOULD20
277	274		OTHERWISE RESULT IN COSTS TO THE GENERAL FUND OR , IF DIRECTED BY21
278	275		THE FEDERAL CENTERS FOR MEDICARE AND MEDICAID SERVICES , THE22
279	276		U
280	277		NITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES , OR ANY23
281	278		OTHER FEDERAL AGENCY. IF A RAC AUDIT IS INITIATED IN RESPONSE TO24
282	279		A FEDERAL DIRECTIVE, THE STATE DEPARTMENT MUST PROVIDE NOTICE TO25
283	280		AN IMPACTED PROVIDER AND INCLUDE THE REASON FOR THE RAC AUDIT26
284	281		AND ANY RELEVANT INFORMATION ABOUT THE FEDERAL REQUIREMENT IN27
285	282		314
286	283		-8- THE NOTICE.1
287	284		(i) (I) T
288	285		HE RAC VENDOR SHALL NOT REQUIRE A PROVIDER TO2
289	286		UNDERGO MORE THAN THREE COMPLEX AUDITS PER CALENDAR YEAR .3
290	287		H
291	288		OSPITALS MUST BE GROUPED FOR COMPLEX AUDITS BASED ON THEIR4
292	289		TOTAL MEDICAID REIMBURSEMENT IN THE PREVIOUS FISCAL YEAR , AND5
293	290		GROUPINGS MUST BE DETERMINED USING STATE DATA AND PUBLISHED6
294	291		ANNUALLY BY THE STATE DEPARTMENT .7
295	292		(II) T
296	293		HE MAXIMUM NUMBER OF MEDICAL RECORD REQUESTS A8
297	294		PROVIDER MAY RECEIVE EACH MONTH MUST BE CLEARLY COMMUNICATED9
298	295		TO PROVIDERS AND REVIEWED ANNUALLY BY THE STATE DEPARTMENT .10
299	296		T
300	297		HE RAC VENDOR SHALL NOT REQUEST MORE THAN THE FOLLOWING11
301	298		NUMBER OF MEDICAL RECORDS PER HOSPITAL PER MONTH :12
302	299		(A) S
303	300		IX HUNDRED FOR HOSPITALS WITH OVER TWO HUNDRED FIFTY13
304	301		MILLION DOLLARS IN MEDICAID REVENUE ;14
305	302		(B) F
306	303		OUR HUNDRED FOR HOSPITALS WITH BETWEEN SEVENTY15
307	304		MILLION DOLLARS AND TWO HUNDRED FORTY -NINE MILLION NINE16
308	305		HUNDRED NINETY-NINE THOUSAND NINE HUNDRED NINETY -NINE DOLLARS17
309	306		IN MEDICAID REVENUE;18
310	307		(C) T
311	308		WO HUNDRED FOR HOSPITALS WITH BETWEEN FORTY MILLION19
312	309		DOLLARS AND SIXTY -NINE MILLION NINE HUNDRED NINETY -NINE20
313	310		THOUSAND NINE HUNDRED NINETY -NINE DOLLARS IN MEDICAID REVENUE;21
314	311		(D) O
315	312		NE HUNDRED FOR HOSPITALS WITH BETWEEN TWENTY22
316	313		MILLION DOLLARS AND THIRTY-NINE MILLION NINE HUNDRED NINETY-NINE23
317	314		THOUSAND NINE HUNDRED NINETY -NINE DOLLARS IN MEDICAID REVENUE;24
318	315		(E) F
319	316		IFTY FOR HOSPITALS WITH BETWEEN TEN MILLION DOLLARS25
320	317		AND NINETEEN MILLION NINE HUNDRED NINETY -NINE THOUSAND NINE26
321	318		HUNDRED NINETY-NINE DOLLARS IN MEDICAID REVENUE ;27
322	319		314
323	320		-9- (F) TWENTY-FIVE FOR HOSPITALS WITH BETWEEN ONE MILLION1
324	321		DOLLARS AND NINE MILLION NINE HUNDRED NINETY -NINE THOUSAND NINE2
325	322		HUNDRED NINETY-NINE DOLLARS IN MEDICAID REVENUE ;3
326	323		(G) T
327	324		WENTY FOR HOSPITALS WITH UNDER ONE MILLION DOLLARS4
328	325		IN MEDICAID REVENUE; AND5
329	326		(H) T
330	327		EN FOR OUT-OF-STATE FACILITIES.6
331	328		(III) T
332	329		HE REQUIREMENTS OF THIS SUBSECTION (3.3)(i) DO NOT7
333	330		APPLY IF:8
334	331		(A) F
335	332		EDERAL MEDICAID DIRECTIVES REQUIRED PURSUANT TO 429
336	333		CFR
337	334		455, SUBPART F, REQUIRE A HIGHER LEVEL OF CLAIM AUDITS;10
338	335		(B) A
339	336		N AGENCY OF THE FEDERAL GOVERNMENT REQUIRES , IN11
340	337		WRITING, THE STATE DEPARTMENT TO INITIATE ADDITIONAL AUDIT12
341	338		ACTIVITY; OR13
342	339		(C) A
343	340		FEDERAL AUDIT IDENTIFIES ADDITIONAL PROVIDER FINDINGS14
344	341		THAT IMPACT THE STATE GENERAL FUND AND THAT SHOULD BE15
345	342		APPROPRIATELY RECOVERED FROM THAT PROVIDER THROUGH AN16
346	343		ADDITIONAL RAC AUDIT AND ITS RECOUPMENTS.17
347	344		(j) (I) T
348	345		HE RAC VENDOR SHALL NOT REQUIRE A PROVIDER TO18
349	346		UNDERGO MORE THAN FOUR AUTOMATED AUDITS PER CALENDAR YEAR .19
350	347		P
351	348		ROVIDERS MUST BE GROUPED FOR AUTOMATED AUDITS BASED ON THEIR20
352	349		TOTAL MEDICAID REIMBURSEMENT IN THE PREVIOUS FISCAL YEAR , AND21
353	350		GROUPINGS MUST BE DETERMINED USING STATE DATA AND PUBLISHED22
354	351		ANNUALLY.23
355	352		(II) T
356	353		HE MAXIMUM NUMBER OF PROVIDER CLAIMS ACROSS ALL OF24
357	354		A PROVIDER'S LOCATIONS FOR A GIVEN CALENDAR YEAR THAT UNDERGO25
358	355		AUTOMATED AUDITS MUST NOT EXCEED :26
359	356		(A) 2.92
360	357		PERCENT FOR PROVIDERS WITH OVER TEN MILLION27
361	358		314
362	359		-10- DOLLARS IN MEDICAID REVENUE ;1
363	360		(B) 2.50
364	361		PERCENT FOR PROVIDERS WITH BETWEEN FOUR MILLION2
365	362		DOLLARS AND TEN MILLION DOLLARS IN MEDICAID REVENUE ;3
366	363		(C) 2.08
367	364		PERCENT FOR PROVIDERS WITH BETWEEN ONE MILLION4
368	365		DOLLARS AND THREE MILLION NINE HUNDRED NINETY -NINE THOUSAND5
369	366		NINE HUNDRED NINETY-NINE DOLLARS IN MEDICAID REVENUE ; AND6
370	367		(D) 1.67
371	368		PERCENT FOR PROVIDERS WITH LESS THAN ONE MILLION7
372	369		DOLLARS IN MEDICAID REVENUE .8
373	370		(III) A
374	371		FTER THE ADMINISTRATIVE PROCESS IS EXHAUSTED , IF THE9
375	372		STATE DEPARTMENT IDENTIFIES A DENIAL RATE OF FORTY PERCENT OR10
376	373		HIGHER FOR A SPECIFIC PROVIDER ON A SPECIFIC AUDIT TYPE , THE STATE11
377	374		DEPARTMENT SHALL AUDIT NO MORE THAN AN ADDITIONAL TWENTY -FIVE12
378	375		PERCENT OF THE CLAIM PERCENTAGES STATED IN SUBSECTION (3.3)(j)(II)13
379	376		OF THIS SECTION ASSOCIATED WITH THAT AUDIT TYPE .14
380	377		(IV) T
381	378		HE REQUIREMENTS OF THIS SUBSECTION (3.3)(j) DO NOT15
382	379		APPLY IF:16
383	380		(A) F
384	381		EDERAL MEDICAID DIRECTIVES REQUIRED PURSUANT TO 4217
385	382		CFR
386	383		455, SUBPART F, REQUIRE A HIGHER LEVEL OF CLAIM AUDITS;18
387	384		(B) A
388	385		N AGENCY OF THE FEDERAL GOVERNMENT REQUIRES , IN19
389	386		WRITING, THE STATE DEPARTMENT TO INITIATE ADDITIONAL AUDIT20
390	387		ACTIVITY; OR21
391	388		(C) A
392	389		FEDERAL AUDIT IDENTIFIES ADDITIONAL PROVIDER FINDINGS22
393	390		THAT IMPACT THE STATE GENERAL FUND AND THAT S HOULD BE23
394	391		APPROPRIATELY RECOVERED FROM THAT PROVIDER THROUGH AN24
395	392		ADDITIONAL RAC AUDIT AND ITS RECOUPMENTS.25
396	393		(k) W
397	394		HEN CONDUCTING AUDITS, THE RAC VENDOR MUST:26
398	395		(I) R
399	396		EQUEST PROVIDER RECORDS THAT ARE RELEVANT TO THE27
400	397		314
401	398		-11- CLAIMS BEING AUDITED AND THAT DO NOT DUPLICATE INFORMATION1
402	399		ALREADY PROVIDED;2
403	400		(II) N
404	401		OT AUDIT THE VALIDITY OF A PROVIDER 'S PRIOR3
405	402		AUTHORIZATION RECEIVED FROM THE STATE DEPARTMENT ; AND4
406	403		(III) F
407	404		OR A COMPLEX AUDIT, NOT AUDIT CLAIMS THAT ARE ON THE5
408	405		FEDERAL CENTERS FOR MEDICARE AND MEDICAID SERVICES6
409	406		INPATIENT-ONLY LIST AT THE DATE OF SERVICE FOR A LEVEL -OF-CARE7
410	407		DETERMINATION.8
411	408
412	409		9
413	410		(l) (I) I
414	411		F THE RAC VENDOR IDENTIFIES PRELIMINARY FINDINGS
415	412		10
416	413		DURING THE RAC AUDIT, THE RAC VENDOR MUST SEND THE PROVIDER A11
417	414		NOTICE OF PRELIMINARY AUDIT FINDINGS DETAILING THE PRELIMINARY12
418	415		FINDINGS, THE RATIONALE FOR THE PRELIMINARY FINDINGS , AND THE13
419	416		METHODOLOGY FOR HOW THE DOLLAR AM OUNTS ASSOCIATED WITH THE14
420	417		PRELIMINARY FINDINGS WERE CALCULATED AND DETERMINED .15
421	418		(II) F
422	419		OR A COMPLEX AUDIT, A PROVIDER MAY REQUEST AN EXIT
423	420		16
424	421		CONFERENCE TO DISCUSS THE PRELIMINARY FINDINGS WITH THE RAC17
425	422		VENDOR AND THE STATE DEPARTMENT MEDICAL DIRECTOR , OR THE STATE18
426	423		DEPARTMENT MEDICAL DIRECTOR 'S DESIGNEE, PRIOR TO PARTICIPATING IN19
427	424		AN INFORMAL RECONSIDERATION . THE PROVIDER MAY PROVIDE20
428	425		ADDITIONAL INFORMATION SUPPORTING THE PROVIDER 'S CLAIMS AT THE21
429	426		EXIT CONFERENCE. A PROVIDER MUST REQUEST AN EXIT CONFERENCE NO22
430	427		LATER THAN THIRTY DAYS AFTER THE PROVIDER RECEIVES A NOTICE OF23
431	428		PRELIMINARY AUDIT FINDINGS FROM THE RAC VENDOR, AND IF AN EXIT24
432	429		CONFERENCE IS REQUESTED , THE STATE DEPARTMENT OR THE RAC25
433	430		VENDOR MUST SCHEDULE THE EXIT CONFERENCE WITHIN SIXTY DAYS OF26
434	431		RECEIVING THE REQUEST AND ON A MUTUALLY AGREED UPON DATE AND27
435	432		314
436	433		-12- TIME.1
437	434		(III) W
438	435		ITHIN THIRTY DAYS OF THE EXIT CONFERENCE , THE STATE
439	436		2
440	437		DEPARTMENT MUST NOTIFY THE PROVIDER ON WHETHER THE STATE3
441	438		DEPARTMENT WILL DISMISS THE PRELIMINARY FINDINGS OR WILL ISSUE A4
442	439		NOTICE OF INFORMAL RECONSIDERATION . THE NOTICE OF INFORMAL5
443	440		RECONSIDERATION MUST INCLUDE DETAILS ON THE PRELIMINARY6
444	441		FINDINGS, THE RATIONALE FOR THE PRELIMINARY FINDINGS , AND THE7
445	442		METHODOLOGY FOR HOW THE DOLLAR AMOUNT ASSOCIATED WITH THE8
446	443		PRELIMINARY FINDINGS WERE CALCULATED AND DETERMINED . IF AN EXIT9
447	444		CONFERENCE OCCURRED , THE NOTICE MUST INCLUDE INFORMATION ON10
448	445		WHY THE STATE DEPARTMENT DID NOT AGREE WITH THE PROVIDER 'S11
449	446		APPROACH.12
450	447		(IV) U
451	448		NLESS THE PRELIMINARY FINDINGS ARE ACCEPTED BY THE
452	449		13
453	450		PROVIDER, DISMISSED BY THE STATE DEPARTMENT FOLLOWING AN EXIT14
454	451		CONFERENCE, OR THE PERIOD FOR A PROVIDER TO REQUEST AN EXIT15
455	452		CONFERENCE HAS EXPIRED , A PROVIDER WHO RECEIVES A NOTICE OF16
456	453		PRELIMINARY FINDINGS, THE STATE DEPARTMENT, AND THE RAC VENDOR17
457	454		MUST PARTICIPATE IN AN INFORMAL RECONSIDERATION BEFORE THE18
458	455		PROVIDER MAY FORMALLY APPEAL THE STATE DEPARTMENT 'S19
459	456		DETERMINATION. TO PARTICIPATE IN AN INFORMAL CONSIDERATION , THE20
460	457		FOLLOWING REQUIREMENTS MUST BE SATISFIED :21
461	458		(A) W
462	459		ITHIN SIXTY DAYS OF RECEIVING THE NOTICE OF INFORMAL
463	460		22
464	461		RECONSIDERATION, THE PROVIDER MUST SUBMIT ALL MEDICAL RECORDS23
465	462		RELEVANT TO THE CLAIMS AND THE REASONING FOR THE PROVIDER 'S24
466	463		DISAGREEMENT CONCERNING THE PRELIMINARY AUDIT FINDINGS . THE25
467	464		MEDICAL RECORDS MUST SUBSTANTIATE THE PROVIDER 'S ARGUMENT TO26
468	465		DISPUTE ANY PRELIMINARY FINDINGS TO ALLOW THE STATE DEPARTMENT27
469	466		314
470	467		-13- AND THE RAC VENDOR TO RECONSIDER THE FINDINGS , AND THE1
471	468		DEPARTMENT AND THE RAC VENDOR MUST REVIEW MEDICAL RECORDS2
472	469		PRIOR TO THE INFORMAL RECONSIDERATION MEETING ;3
473	470		(B) T
474	471		HE STATE DEPARTMENT MUST SCHEDULE AN INFORMAL
475	472		4
476	473		RECONSIDERATION MEETING BETWEEN MUTUALLY AGREED UPON5
477	474		PARTICIPANTS FROM THE STATE DEPARTMENT , RAC VENDOR, AND6
478	475		PROVIDER REPRESENTATIVES AT A MUTUALLY AGREED UPON DATE AND7
479	476		TIME WITHIN NINETY DAYS OF ISSUING THE NOTICE OF INFORMAL8
480	477		RECONSIDERATION, ALTHOUGH EITHER PARTY MAY REQUEST A SIXTY -DAY9
481	478		EXTENSION; AND10
482	479		(C) A
483	480		LL AGREED UPON ATTENDEES MUST PARTICIPATE IN THE
484	481		11
485	482		INFORMAL RECONSIDERATION MEETING IN GOOD FAITH IN AN EFFORT TO12
486	483		RESOLVE THE DISPUTE.13
487	484		(V) I
488	485		F A CLAIM REMAINS IN DISPUTE AFTER THE INFORMAL
489	486		14
490	487		RECONSIDERATION MEETING , THE STATE DEPARTMENT MUST ISSUE A15
491	488		NOTICE OF ADVERSE ACTION WITHIN SIXTY DAYS OF THE INFORMAL16
492	489		RECONSIDERATION MEETING . THE NOTICE OF ADVERSE ACTION MUST17
493	490		INCLUDE THE BASIS OF THE ALLEGED OVERPAYMENT , THE RATIONALE FOR18
494	491		THE ALLEGED OVERPAYMENT , THE METHODOLOGY USED TO CALCULATE19
495	492		THE ALLEGED OVERPAYMENT , AND INFORMATION ON WHY THE STATE20
496	493		DEPARTMENT DID NOT AGREE WITH THE PROVIDER 'S APPROACH.21
497	494		(VI) W
498	495		ITHIN THIRTY DAYS OF RECEIVING A NOTICE OF ADVERSE
499	496		22
500	497		ACTION, THE PROVIDER MAY REQUEST A FORMAL APPEAL , WHICH MUST23
501	498		INCLUDE AN EXPLANATION OF THE BASIS OF THE APPEAL IN ACCORDANCE24
502	499		WITH RULES ADOPTED BY THE STATE DEPARTMENT .25
503	500		(VII) T
504	501		HE STATE DEPARTMENT MUST NOT RECOVER AN
505	502		26
506	503		OVERPAYMENT IDENTIFIED IN THE PRELIMINARY FINDINGS FROM A27
507	504		314
508	505		-14- PROVIDER UNTIL THE INFORMAL RECONSIDERATION PROCESS , AND1
509	506		SUBSEQUENT FORMAL APPEAL , IF FILED, ARE COMPLETE.2
510	507		(VIII) I
511	508		F THE STATE DEPARTMENT HAS NOT ISSUED A NOTICE OF
512	509		3
513	510		ADVERSE ACTION ONE HUNDRED TWENTY DAYS FOLLOWING THE INFORMAL4
514	511		RECONSIDERATION MEETING , THE STATE DEPARTMENT WAIVES ITS RIGHT5
515	512		TO RECOVER THE STATE SHARE OF THE OVERPAYMENT .6
516	513		(m) PROVIDERS ARE SUBJECT TO ALL STATE AND FEDERAL7
517	514		MEDICAID FRAUD, WASTE, AND ABUSE LAWS AND MUST COMPLY WITH ALL8
518	515		APPLICABLE PROGRAM INTEGRITY REQUIREMENTS . FAILURE TO COMPLY9
519	516		MAY RESULT IN REMOVAL FROM THE STATE MEDICAL ASSISTANCE10
520	517		PROGRAM, FINANCIAL PENALTIES, CIVIL LAWSUITS, OR CRIMINAL11
521	518		PROSECUTION PURSUANT TO 42 U.S.C. SEC. 1320a-7k(d), 42 U.S.C. SEC.12
522	519		1320a-7, 31
523	520		U.S.C. SECS. 3729-3733, SECTIONS 24-31-808, 25.5-4-301,13
524	521		25.5-4-303.5
525	522		TO 25.5-4-310, AND 10 CCR 2505-10, SEC. 8.076. BY14
526	523		PARTICIPATING IN THE MEDICAL ASSISTANCE PROGRAM , PROVIDERS15
527	524		ACKNOWLEDGE AND ACCEPT THEIR OBLIGATION TO ADHERE TO ALL STATE16
528	525		AND FEDERAL LAWS GOVERNING MEDICAID FRAUD , WASTE, AND ABUSE,17
529	526		AND PROGRAM INTEGRITY.18
530	527		(n)
531	528		(I) THE STATE DEPARTMENT SHALL PUBLISH AND MAINTAIN ON19
532	529		ITS WEBSITE A RAC AUDIT ACTIVITY REPORT FOR EACH RAC AUDIT AND20
533	530		REVIEW COMPLETED IN THE PRECEDING YEAR SUMMARIZING THE FINDINGS21
534	531		OF THOSE RAC AUDITS AND REVIEWS. THE INFORMATION POSTED ON THE22
535	532		STATE DEPARTMENT'S WEBSITE CONCERNING EACH RAC AUDIT MUST23
536	533		INCLUDE THE FOLLOWING INFORMATION :24
537	534		(A) A
538	535		SUMMARY OF THE AUDIT SCENARIO , THE STATE25
539	536		DEPARTMENT'S BILLING PRACTICES, AND POLICY GUIDELINES BEING26
540	537		REVIEWED BY THE RAC VENDOR;27
541	538		314
542	539		-15- (B) THE ERROR RATES IDENTIFIED DURING THE RAC VENDOR'S1
543	540		REVIEW;2
544	541		(C) T
545	542		HE NUMBER AND AMOUNTS OF OVERPAYMENTS AND3
546	543		UNDERPAYMENTS IDENTIFIED BY THE RAC VENDOR;4
547	544		(D) T
548	545		HE RECOVERIES COLLECTED BY THE STATE DEPARTMENT ON5
549	546		IDENTIFIED OVERPAYMENTS;6
550	547		(E) T
551	548		HE NUMBER OF CLAIMS APPEALED AS A RESULT OF THE AUDIT ;7
552	549		AND8
553	550		(F) D
554	551		ETAILS ON THE AUDIT SCENARIOS AND BILLING STANDARDS9
555	552		USED BY THE RAC VENDOR AND POLICY GUIDANCE ON PROPER BILLING10
556	553		PRACTICES.11
557	554		(II) I
558	555		N ADDITION TO THE INFORMATION REQUIRED BY SUBSECTION12
559	556		(3.3)(n)(I)
560	557		OF THIS SECTION, THE STATE DEPARTMENT SHALL PUBLISH AND13
561	558		MAINTAIN ON ITS WEBSITE INFORMATION ON THE NUMBER OF INFORMAL14
562	559		RECONSIDERATION MEETINGS THE STATE DEPARTMENT PARTICIPATED IN15
563	560		AND THE ASSOCIATED PERCENTAGE OF FINDINGS THAT WERE UPHELD , THE16
564	561		NUMBER OF APPEALS, AND CORRESPONDING DETERMINATIONS .17
565	562		(o) ON OR BEFORE JANUARY 1, 2026, THE STATE DEPARTMENT18
566	563		SHALL PUBLISH ON ITS WEBSITE PROVIDER EDUCATION INFORMATION ;19
567	564		RESOURCES TO ASSIST PROVIDERS IN UNDERSTANDING THE STATE20
568	565		DEPARTMENT'S MEDICAID BILLING MANUAL AND RULES; AND PROCEDURES21
569	566		RELATED TO RAC AUDITS, INCLUDING DOCUMENTATION REQUIREMENTS22
570	567		AND THE PROCESS FOR RESOLVING DISPUTES .23
571	568		(p) AT LEAST QUARTERLY, THE STATE DEPARTMENT SHALL :24
572	569		(I) C
573	570		ONDUCT MEDICAID BILLING TRAINING FOR PROVIDERS AND25
574	571		HOLD MEETINGS WITH PROVIDERS TO GATHER FEEDBACK ON THE RAC26
575	572		AUDIT PROCESS. THE STATE DEPARTMENT SHALL PUBLISH MEETING DATES27
576	573		314
577	574		-16- AND TIMES ON THE STATE DEPARTMENT 'S WEBSITE AT LEAST TWO WEEKS1
578	575		PRIOR TO THE MEETINGS.2
579	576		(II) C
580	577		ONDUCT TRAININGS FOR PROVIDERS AND HOLD3
581	578		STAKEHOLDER MEETINGS REGARDING AUDITS AND REVIEWS , DURING4
582	579		WHICH THE STATE DEPARTMENT AND RAC VENDOR MUST IDENTIFY5
583	580		COMMON BILLING ERRORS IDENTIFIED BY THE RAC VENDOR IN THE6
584	581		PREVIOUS QUARTER AND PROVIDE CLARIFICATION ON THE BILLING ERRORS .7
585	582		(q)
586	583		THE STATE DEPARTMENT SHALL WORK WITH SMALL OR RURAL8
587	584		PROVIDERS IN ORDER TO IDENTIFY AND IMPLEMENT OPPORTUNITIES TO9
588	585		REDUCE ADMINISTRATIVE BURDENS AND BETTER SUPPORT COMPLIANCE10
589	586		WITH MEDICAID BILLING PRACTICES , AS ADOPTED IN THE STATE11
590	587		DEPARTMENT'S MEDICAID BILLING MANUAL, AND EXPERIENCE WITH RAC12
591	588		AUDITS.13
592	589		(r) THE STATE DEPARTMENT MUST SUBMIT AN ANNUAL REPORT TO14
593	590		THE JOINT BUDGET COMMITTEE THAT INCLUDES A DESCRIPTION OF THE15
594	591		FOLLOWING:16
595	592		(I) T
596	593		HE DIVISIONS OF THE STATE DEPARTMENT THAT ARE17
597	594		INCLUDED IN THE REVIEW AND APPROVAL OF RAC AUDIT SCENARIOS AND18
598	595		THE ROLES AND RESPONSIBILITIES OF EACH DIVISION;19
599	596		(II) T
600	597		HE RAC VENDOR'S COMPLIANCE WITH THE RESPONSE20
601	598		REQUIREMENT DESCRIBED IN SUBSECTION (3.3)(c)(III)(C) OF THIS21
602	599		SECTION;22
603	600		(III) T
604	601		HE STATE DEPARTMENT'S OVERSIGHT AND ENFORCEMENT OF23
605	602		THE CONTRACTUAL REQUIREMENT THAT THE RAC VENDOR CONDUCT24
606	603		INFORMAL CONFERENCES OR PHONE CALLS WITH PROVIDERS OR PROVIDER25
607	604		ASSOCIATIONS TO DISCUSS THE RAC PROGRAM, APPEAL PROCESSES, AND26
608	605		FINDINGS;27
609	606		314
610	607		-17- (IV) THE TRAINING MATERIALS PREPARED BY THE RAC VENDOR1
611	608		AFTER EACH RAC AUDIT THAT IDENTIFY AND ADDRESS THE COMMON2
612	609		ERRORS AND ISSUES IDENTIFIED DURING THE AUDIT AND THE CONTENT3
613	610		AND MATERIALS THE RAC VENDOR USED TO EDUCATE PROVIDERS TO4
614	611		PREVENT ERRORS IN THE FUTURE;5
615	612		(V) A
616	613		SUMMARY OF THE RAC VENDOR'S OUTREACH AND6
617	614		EDUCATION ACTIVITIES;7
618	615		(VI) A
619	616		SUMMARY OF THE STATE DEPARTMENT 'S WRITTEN POLICIES,8
620	617		PROCEDURES, AND GUIDANCE THAT ESTABLISH PROCESSES FOR THE STATE9
621	618		DEPARTMENT TO LOG PROVIDER COMMUNICATIONS , PROVIDE DIRECTION10
622	619		ON HOW STATE DEPARTMENT STAFF MUST RESPOND TO COMMUNICATIONS11
623	620		IN A TIMELY AND RELEVANT MANNER , AND HOW THE STATE DEPARTMENT12
624	621		INSTITUTED ROUTINE ANALYSIS OF PROVIDER COMMUNICATIONS TO13
625	622		INFORM DECISIONS ON PROGRAM IMPROVEMENTS ; AND14
626	623		(VII) T
627	624		HE TOTAL AMOUNT OF ALLEGED OVERPAYMENTS15
628	625		IDENTIFIED BY THE RAC VENDOR, THE PROPORTION OF THOSE16
629	626		OVERPAYMENTS THAT WERE RECOVERED , AND THE TOTAL AMOUNT PAID17
630	627		TO THE RAC VENDOR.18
631	628		(s)
632	629		ALL RECOVERIES COLLECTED BY THE STATE DEPARTMENT ON19
633	630		IDENTIFIED OVERPAYMENTS PURSUANT TO THIS SUBSECTION (3.3) MUST BE20
634	631		TRANSMITTED TO THE STATE TREASURER , WHO SHALL CREDIT THE SAME21
635	632		TO THE RECOVERY AUDIT CONTRACTOR RECOVERIES CASH FUND , WHICH22
636	633		FUND IS CREATED IN THE STATE TREASURY AND REFERRED TO IN THIS23
637	634		SUBSECTION (3.3)(s) AS THE "CASH FUND". THE CASH FUND CONSISTS OF24
638	635		MONEY CREDITED TO THE CASH FUND PURSUANT TO THIS SUBSECTION (3.3)25
639	636		AND ANY OTHER MONEY THAT THE GENERAL ASSEMBLY MAY APPROPRIATE26
640	637		OR TRANSFER TO THE CASH FUND. SUBJECT TO ANNUAL APPROPRIATION BY27
641	638		314
642	639		-18- THE GENERAL ASSEMBLY, THE STATE DEPARTMENT MAY EXPEND MONEY1
643	640		FROM THE CASH FUND TO OFFSET THE NEED FOR APPROPRIATIONS FOR2
644	641		MEDICAL SERVICES AND TO PAY THE RAC VENDOR. THE STATE3
645	642		TREASURER SHALL CREDIT ALL INTEREST AND INCOME DERIVED FROM THE4
646	643		DEPOSIT AND INVESTMENT OF MONEY IN THE RECOVERY AUDIT5
647	644		CONTRACTOR RECOVERIES CASH FUND TO THE CASH FUND .6
648	645		(t) THE STATE DEPARTMENT MAY ADOPT RULES , AS NECESSARY, TO7
649	646		IMPLEMENT THE REQUIREMENTS OF THIS SUBSECTION (3.3).8
650	647		(3.5) (c) (I) The state department shall create a provider advisory9
651	648		group for recovery audits consisting of employees of the state department10
652	649		and members from different provider groups TYPES, including physicians,11
653	650		hospitals, and any other provider types directly impacted by audits12
654	651		conducted pursuant to this section, appointed by the executive director.13
655	652		The provider advisory group shall meet at least quarterly to review14
656	653		quarterly activity reports required by subsection (3)(a)(IX) SUBSECTION15
657	654		(3.3)(n) of this section and advise the state department on issues providers16
658	655		experience with audits of the recovery audit contractors program.17
659	656		(II) T
660	657		HE STATE DEPARTMENT AND THE RAC VENDOR SHALL18
661	658		PROVIDE THE PROVIDER ADVISORY GROUP WITH THE OPPORTUNITY TO19
662	659		REVIEW RAC AUDIT SCENARIOS DURING THE PROVIDER ADVISORY GROUP 'S20
663	660		QUARTERLY MEETINGS.21
664	661		(III) T
665	662		HE STATE DEPARTMENT SHALL GIVE PROVIDERS THE22
666	663		OPPORTUNITY TO ANONYMOUSLY DESCRIBE RAC AUDIT SCENARIOS THEY23
667	664		ARE EXPERIENCING AND ASK QUESTIONS ABOUT BILLING PRACTICES . THE24
668	665		STATE DEPARTMENT SHALL INCLUDE RAC VENDOR STAFF AND THE25
669	666		RELEVANT STATE DEPARTMENT DIVISION STAFF IN THESE DISCUSSIONS . IF26
670	667		THE DISCUSSIONS LEAD THE STATE DEPARTMENT TO DETERMINE THAT AN27
671	668		314
672	669		-19- AUDIT SCENARIO WAS INACCURATE , THE STATE DEPARTMENT MUST WORK1
673	670		WITH THE RAC VENDOR TO RESCIND THE RAC AUDIT.2
674	671		SECTION 2. Appropriation adjustments to 2025 long bill.3
675	672		(1) To implement this act, appropriations made in the annual general4
676	673		appropriation act for the 2025-26 state fiscal year to the department of5
677	674		health care policy and financing for medical and long-term care services6
678	675		for medical-eligible individuals are adjusted as follows:7
679	676		(a) The cash funds appropriation from recoveries and recoupments8
680	677		is decreased by $20,900,588;9
681	678		(b) The cash funds appropriation from the recovery audit10
682	679		contractor recoveries cash fund created in section 25.5-4-301 (3.3)(s),11
683	680		C.R.S., is increased by $20,900,588.12
684	681		SECTION 3. Act subject to petition - effective date. This act13
685	682		takes effect at 12:01 a.m. on the day following the expiration of the14
686	683		ninety-day period after final adjournment of the general assembly; except15
687	684		that, if a referendum petition is filed pursuant to section 1 (3) of article V16
688	685		of the state constitution against this act or an item, section, or part of this17
689	686		act within such period, then the act, item, section, or part will not take18
690	687		effect unless approved by the people at the general election to be held in19
691	688		November 2026 and, in such case, will take effect on the date of the20
692	689		official declaration of the vote thereon by the governor.21
693	690		314
694	691		-20-