Medicaid; establishing certain requirements and procedures for audits of providers; directing establishment of certain appeals. Effective date.

Added 'long-term care provider' as a distinct definition and expanded the list of covered entities to include nursing facilities, ICF/IID, home- and community-based services providers, and PACE organizations.

Modified audit limitations to distinguish between long-term care providers and all other providers, allowing a higher claim review threshold (5%) for long-term care providers while keeping the two-audit-per-year limit.

Changed the bill title from 'Committee Substitute' to 'Floor Substitute' and updated the page header numbers to reflect the new version.

Removed specific limitations on the number of claims audited based on provider type (long-term care vs. others) and replaced them with a general rule auditing the greater of 50 claims or 0.25% of billed claims for all providers.

Changed the rule for selecting audit methods from authority discretion (with exceptions) to provider discretion.

Reorganized the bill text, added page headers and footers, and updated the legislative session year to 2026.

Minor formatting changes to the definition of 'Audit' and the list of clerical errors.

Added a requirement that audits involving clinical judgment must be conducted in consultation with state agencies that license or oversee the provider.

Added a protection preventing the Authority from citing providers for errors based on compliance with rules from other state agencies with which the provider is also contracted.

Modified recoupment rules to allow the Authority to recover the entire overpaid claim if the corrected claim is issued on the same date as the original payment.

Adjusted the scope of non-fraud audits for long-term care providers, changing the threshold from a percentage of claims to a specific percentage (0.25%) or a fixed number of claims (50), whichever is greater.

Added a formal 'SUBJECT' line to the bill text.

Updated the list of bill sponsors to include 'Williams of the House' in addition to the original sponsors.

Changed the target audience of the audit rules from 'long-term care providers' to 'Medicaid providers' to include a broader range of healthcare entities.

Added definitions for 'Capitated contract' and 'contracted entity' to clarify who can conduct audits alongside the Authority.

Modified the audit selection process to allow providers to choose the method of review (on-site, electronic, or remote) instead of the Authority deciding the method.

Updated the audit frequency limit to apply to all providers, not just long-term care providers, restricting audits to a maximum of two times per calendar year.

Expanded the scope of audits to include all providers, not just long-term care providers, when determining sample sizes for review.