Frequently Asked Questions

What is the RAC’s lookback period for reviewing claims?

The RAC program lookback period is 3 years from the most recent date of payment.
Will the RAC review all claims at one time for the provider?

All claims are analyzed based on the approved Improper Payment Scenarios for underpayments or overpayments. As new Improper Payment Scenarios are approved, all claims will undergo similar analysis for potential improper payments.
How are claims selected for an automated or complex review?

All claims are selected based on an approved Improper Payment Scenario. Improper Payment Scenarios are broken into two types of reviews, automated reviews and complex reviews.

Automated Reviews
Identification of improper payments both overpayments and underpayments are generated using data analytics, applying strict and clear policy guidelines either at the state or federal level supporting the improper payment finding. No medical records are required, requested, or reviewed to determine the improper payment during an automated review.

Complex Reviews
Claims are selected using analytics that indicate a high likelihood to result in a potential improper payment. Notices are sent to providers requesting the submission of medical records and/or supporting documentation for the selected claims. At which time, Alivia will review the medical records to confirm if the claim was billed and paid correctly.
Is there a listing of all automated/complex reviews?

Yes, all approved automated and complex reviews are listed on Alivia’s dedicated Alabama Medicaid Agency RAC website.

Navigate to Alivia’s Alabama Medicaid RAC website. Under Provider Resources on the navigational panel on the left side, select the Improper Payment Scenarios option. This will direct you to the Improper Payment Scenarios page.

This listing will include the Scenario Name, Scenario Type, Date Started, and Date Concluded.

Scenario Name: High level naming convention to reference the automated/complex review
Scenario Type: Clearly notates if the scenario is an automated review or complexreview
Date Started: Date the scenario was approved by the Agency for Alivia to conduct reviews
Date Concluded: Date the Agency confirms the scenario no longer active for additional reviews
How do I enroll in the provider portal?

Navigate to Alivia’s Alabama Medicaid RAC website. Under Provider Resources on the navigational panel on the left side, select the Provider Portal option. This will direct you to the Provider Portal for enrollment and user guides.
Will the RAC be conducting in person or remote reviews?

All RAC reviews will be conducted remotely.
What is the timeline to submit medical records?

All medical records are due within 20 business days from the date of the Medical Records Request Letter.
What do I do if I need an extension to submit medical records?

Extensions are available in extenuating circumstances. You may contact Alivia’s provider services team for assistance. Alivia’s contact information can be found on the Contact Information page of the Alabama Medicaid RAC website.
What will occur if I don’t respond to the medical records request?

All medical records are due within the timeframe specified on the Medical Record Request Letter. Failure to submit documentation for services billed to Alabama Medicaid in a timely manner will result in the recoupment of all funds for claims paid for those dates.
What will occur if I didn’t send the correct or complete medical records?

Following a review of all submitted documentation, Alivia will issue a Draft Complex Audit Letter which outlines its initial findings. Providers have an opportunity to request an Informal Conference in which the provider can submit the appropriate medical records for Alivia to reevaluate the improper payment findings.
What is the timeline to submit an Informal Conference request?

Providers have 15 calendar days from the date of the Draft Audit Letter or Automated Audit Letter to request an Informal Conference.
After the Draft Audit Letter, do I have an opportunity to submit documentation?

In order for complex claims to be reevaluated the following should be submitted as outlined in the Draft Audit Letter.

Submit any additional documentation to respond to the Draft Audit Letter
Include a copy of the Itemized Claims Report indicating whether you agree or disagree with each finding
• Submit additional documentation for the claim findings that you did not previously send
• Send supporting documents as justification, that can fully support your reason for disagreeing for the
• Explanation of Review attached with the Draft Audit Letter

In order for automated claims to be reevaluated the following should be submitted as outlined in the Automated Audit Letter.
• Submit documentation that supports why the claim should not be considered overpaid
• Include specific findings, documentation, and billing guidelines that are specific to Alabama Medicaid claim reimbursements that support payment for the claim
What will occur if I don’t respond to the Complex Draft Audit Letter?

Alivia will issue a Final Audit Letter which will finalize the findings from the Draft Audit Letter and provide instructions for next steps in the review process.
What are my appeal rights after the Final Audit Letter is received, if I disagree with the findings?

If a provider disagrees with Alivia’s final decision listed in the Final Audit Letter, the provider or the provider’s representative may request a Fair Hearing. All Fair Hearing requests must be in writing, dated, signed, and filed within 60 calendar days from the date of the Final Audit Letter. The request should contain a statement as to the specific findings in dispute, the basis for the provider’s position that the specific findings are incorrect and must contain supporting documentation as noted on the provided Explanation of Review. It is important to note that a recoupment will not be avoided during the time a provider is allotted to request a hearing.
What will occur if I don’t respond to the Final Audit Letter?

If a provider does not respond to the Final Audit Letter, the Agency will initiate a recoupment for the improper payment amount listed in the Final Audit Letter.
Will identified overpayments be recouped prior to the appeal?

Yes, providers may have recoupments occur during the appeal process. Submitting a Fair Hearing request does not prevent recoupments from occurring.
How will the RAC recover payments from providers?

Providers have two options to reimburse Alabama Medicaid for identified overpayments, either through a refund check directly to the Agency or through future checkwrites. Please carefully follow the instructions provided in the Final Audit Letter to ensure recoupments are received and that your account is properly credited.

1. What is the RAC’s lookback period for reviewing claims?

The RAC program lookback period is 3 years from the most recent date of payment.

2. Will the RAC review all claims at one time for the provider?

All claims are analyzed based on the approved Improper Payment Scenarios for underpayments or overpayments. As new Improper Payment Scenarios are approved, all claims will undergo similarly analysis for potential improper payments.

3. How are claims selected for an automated or complex review?

All claims are selected based on an approved Improper Payment Scenario. Improper Payment Scenarios are broken into two types of reviews, automated reviews and complex reviews.

Automated Reviews
Identification of improper payments both overpayments and underpayments are generated using data analytics, applying strict and clear policy guidelines either at the state or federal level supporting the improper payment finding. No medical records are required, requested, or reviewed to determine the improper payment during an automated review.

Complex Reviews
Claims are selected using analytics that indicate a high likelihood to result in a potential improper payment. Notices are sent to providers requesting the submission of medical records and/or supporting documentation for the selected claims. At which time, Alivia will review the medical records to confirm if the claim was billed and paid correctly.

4. Is there a listing of all automated/complex reviews?

Yes, all approved automated and complex reviews are listed on Alivia’s dedicated Alabama Medicaid Agency RAC website.

Navigate to Alivia’s Alabama Medicaid RAC website. Under Provider Resources on the navigational panel on the left side, select the Improper Payment Scenarios option. This will direct you to the Improper Payment Scenarios page.

This listing will include the Scenario Name, Scenario Type, Date Started, and Date Concluded.

Scenario Name: High level naming convention to reference the automated/complex review

Scenario Type: Clearly notates if the scenario is an automated review or complexreview

Date Started: Date the scenario was approved by the Agency for Alivia to conduct reviews

Date Concluded: Date the Agency confirms the scenario no longer active for additional reviews

5. How do I enroll in the provider portal?

Navigate to Alivia’s Alabama Medicaid RAC website. Under Provider Resources on the navigational panel on the left side, select the Provider Portal option. This will direct you to the Provider Portal for enrollment and user guides.

6. Will the RAC be conducting in person or remote reviews?

All RAC reviews will be conducted remotely.

7. What is the timeline to submit medical records?

All medical records are due within 20 business days from the date of the Medical Records Request Letter.

8. What do I do if I need an extension to submit medical records?

Extensions are available in extenuating circumstances. You may contact Alivia’s provider services team for assistance. Alivia’s contact information can be found on the Contact Information page of the Alabama Medicaid RAC website.

9. What will occur if I don’t respond to the medical records request?

All medical records are due within the timeframe specified on the Medical Record Request Letter. Failure to submit documentation for services billed to Alabama Medicaid in a timely manner will result in the recoupment of all funds for claims paid for those dates.

10. What will occur if I didn’t send the correct or complete medical records?

Following a review of all submitted documentation, Alivia will issue a Draft Complex Audit Letter which outlines its initial findings. Providers have an opportunity to request an Informal Conference in which the provider can submit the appropriate medical records for Alivia to reevaluate the improper payment findings.

11. What is the timeline to submit an Informal Conference request?

Providers have 15 calendar days from the date of the Draft Audit Letter or Automated Audit Letter to request an Informal Conference.

12. After the Draft Audit Letter, do I have an opportunity to submit documentation?

In order for complex claims to be reevaluated the following should be submitted as outlined in the Draft Audit Letter.

Submit any additional documentation to respond to the Draft Audit Letter
Include a copy of the Itemized Claims Report indicating whether you agree or disagree with each finding

Submit additional documentation for the claim findings that you did not previously send
Send supporting documents as justification, that can fully support your reason for disagreeing for the
Explanation of Review attached with the Draft Audit Letter

In order for automated claims to be reevaluated the following should be submitted as outlined in the Automated Audit Letter.

Submit documentation that supports why the claim should not be considered overpaid
Include specific findings, documentation, and billing guidelines that are specific to Alabama Medicaid claim reimbursements that support payment for the claim

13. What will occur if I don’t respond to the Complex Draft Audit Letter?

Alivia will issue a Final Audit Letter which will finalize the findings from the Draft Audit Letter and provide instructions for next steps in the review process.

14. What are my appeal rights after the Final Audit Letter is received, if I disagree with the findings?

If a provider disagrees with Alivia’s final decision listed in the Final Audit Letter, the provider or the provider’s representative may request a Fair Hearing. All Fair Hearing requests must be in writing, dated, signed, and filed within 60 calendar days from the date of the Final Audit Letter. The request should contain a statement as to the specific findings in dispute, the basis for the provider’s position that the specific findings are incorrect and must contain supporting documentation as noted on the provided Explanation of Review. It is important to note that a recoupment will not be avoided during the time a provider is allotted to request a hearing.

15. What will occur if I don’t respond to the Final Audit Letter?

If a provider does not respond to the Final Audit Letter, the Agency will initiate a recoupment for the improper payment amount listed in the Final Audit Letter.

16. Will identified overpayments be recouped prior to the appeal?

Yes, providers may have recoupments occur during the appeal process. Submitting a Fair Hearing request does not prevent recoupments from occurring.

17. How will the RAC recover payments from providers?

Providers have two options to reimburse Alabama Medicaid for identified overpayments, either through a refund check directly to the Agency or through future checkwrites. Please carefully follow the instructions provided in the Final Audit Letter to ensure recoupments are received and that your account is properly credited.