10A NCAC 22F .0508. PEER REVIEW PROCEDURES

(a)  The chairman of the Peer Review Board shall have complete control over the conduct of the review proceedings and will be responsible for:

(1)           calling the review to order;

(2)           stating the purpose of the review;

(3)           recognizing speakers and witnesses;

(4)           ensuring that presentations are pertinent and non‑repetitious;

(5)           ensuring that the provider has a full and fair opportunity to present his defense and question or rebutt the persons presenting the Medicaid Agency's case;

(6)           having a record made of the proceedings which must include The Peer Review Board's findings, conclusions, and recommendations; and

(7)           proceedings where oral evidence is presented shall be tape recorded, but need not be transcribed unless a party to the proceedings requests a transcript.  The party requesting a transcript, or part thereof, must pay for the transcript.  Either party may provide a court reporter at its expense.

(b)  After all the evidence has been heard and all the presented material has been reviewed, The Peer Review Board must make findings of fact and conclusions based solely on what was presented to the Board.  All conclusions of the Board shall be made by majority vote.

(c)  In rendering its conclusions the Board shall decide if the care furnished by the provider appearing before the Board was, by comparison to care furnished by other like professionals in North Carolina:

(1)           appropriate, necessary, and of acceptable quality;

(2)           inappropriate;

(3)           unnecessary; or

(4)           of unacceptable quality.

(d)  The findings and conclusions of the board shall be issued in writing to the Division and provider within thirty days following the review.  Any board member who disagrees with the decision may file a written statement of his reasons.

(e)  The Peer Review Board may forward along with its findings and conclusions, a set of recommendations to the Division and the provider. The Board may recommend that:

(1)           a program be established to monitor the provider's future Medicaid practice to ensure that it is once again within Medicaid guidelines;

(2)           the case be referred to the N.C. State Medicaid Fraud Control Unit for investigation of possible fraud;

(3)           the case be referred to the appropriate state board of examiners or to the Mediation Committee of the appropriate professional organization;

(4)           other appropriate actions be taken to assure that appropriate, necessary, quality care is provided to Medicaid recipients.

(f)  The Division of Medical Assistance shall have the authority to impose sanctions, remedial measures, and recoupment actions against the provider.  The Division of Medical Assistance is not bound by the Peer Review Board's recommendations; it is bound by the Board's findings of fact and conclusions regarding medical issues.  The Division of Medical Assistance's decision shall be in writing and shall contain a statement of the provider's provisions of 10A NCAC 01.  In processing the findings, the Director of the Division of Medical Assistance shall serve as the Secretary's designee and shall be responsible for making the final agency decision.

 

History Note:        Authority G.S. 108A‑25(b); 150B‑11; 42 C.F.R. Part 455; 42 C.F.R. Part 456;

Eff. May 1, 1984;

Amended Eff. May 1, 1990; September 1, 1988; January 1, 1987.