Section 52.63. Provider misutilization and abuse

(a) If the Department’s audit, financial review or monitoring indicates that a provider has been billing for services in a manner inconsistent with this chapter, unnecessary or inappropriate to a participant’s needs, or contrary to customary standards of practice, the Department will notify the provider in writing that payment on all invoices will be delayed or suspended for a period not to exceed 120 days pending a review of billing and service patterns.

(b) A provider may have its invoices reviewed prior to payment.

(c) A provider’s records may be reviewed.

(d) A provider may be required to submit a written explanation of billing practices.