North Carolina's Medicaid program integrity reviews run on a longer appeal clock than the rule once allowed. The state's Office of Compliance and Program Integrity (OCPI), through contractor Public Consulting Group (PCG), issues a tentative notice of overpayment after a statistically sampled claims audit. A provider's entire right to contest that finding runs on two deadlines inside 10A NCAC 22F .0402: 30 business days to request a reconsideration review, and, if that review does not resolve the matter, 60 days to file a contested case petition with the North Carolina Office of Administrative Hearings (OAH). Missing either deadline makes the overpayment final.
North Carolina's Program Integrity Audit Process
OCPI is the NC Medicaid division responsible for stopping fraud, waste, and abuse in the program, and it contracts with PCG to run the state's post-payment reviews. PCG selects a statistically valid sample of a provider's paid claims, audits that sample against the applicable billing policy, and extrapolates any error rate across the full population of claims reviewed, which is why a sample of claims can produce a demand far larger than the sample itself. The billing patterns that put a provider into that sample are the subject of Medicaid Audit Triggers: How State Agencies Select Providers. When the pattern looks like more than an isolated billing error, the same facts can support a parallel false claims act referral, not just a civil overpayment.
The Reconsideration Review Deadline
A provider who wants to contest a tentative notice of overpayment must submit a written request for a reconsideration review within 30 business days of receiving the notice, under 10A NCAC 22F .0402(b). NC Medicaid extended that window in 2018; the rule previously gave providers only 15 working days. Missing the 30-business-day deadline does not leave the overpayment open for later discussion. It converts the tentative decision into the Division's final decision by operation of the rule itself, leaving only the recoupment schedule to work out. A provider's best position going into that window is the documentation discipline described in Medicaid Audit Preparation Checklist for Provider Offices, built before the audit notice arrives.
A provider that lets the 30-business-day window close has no further say in the overpayment: the tentative notice becomes the Division's final decision by operation of the rule itself.
What Happens at a Reconsideration Review
Once a reconsideration request is timely filed, NC Medicaid must schedule the review within 30 business days of receiving it, a deadline also extended from the 20 calendar days the rule previously allowed. Before the review, the provider must submit a written statement identifying the specific claims it disputes and its reasons for disputing them. The review clarifies the issues, exchanges the investigative file, and reconsiders both the administrative measures and the restitution amount. The sample claims reviewed, and the period they were drawn from, are the lookback mechanics covered in Medicaid Audit Lookback Periods and the Sample Time Frame. NC Medicaid sends the decision by certified mail within 30 business days after the review record closes, itself extended from the five working days the rule gave the Division before 2018.
Filing a Contested Case Petition With the Office of Administrative Hearings
If the reconsideration review decision does not resolve the matter, the provider has 60 days from receipt of that decision to file a contested case petition with the North Carolina Office of Administrative Hearings, under G.S. 150B-23(f). That petition is the formal audit appeal stage: it opens a contested case before an administrative law judge, separate from the Division's own reconsideration process. A provider who does not file within the 60-day window loses the right to further review; the reconsideration decision becomes the Division's final decision.
Why Early Legal Counsel Is Critical
It is critical that North Carolina Medicaid providers promptly retain experienced healthcare defense counsel upon receiving a tentative notice of overpayment, an additional documentation request, or any other OCPI inquiry. Early legal intervention can protect the provider's rights, calendar both the 30-business-day reconsideration deadline and the 60-day OAH petition deadline, avoid inadvertent admissions during the reconsideration review, and preserve the defenses available at each appeal stage. Delaying representation can significantly affect the outcome of the review and expose the provider to a larger extrapolated recoupment or a parallel OIG exclusion referral.
How Health Law Alliance Can Help
Health Law Alliance defends healthcare providers through NC Medicaid program integrity audits, reconsideration reviews, and contested case hearings before the Office of Administrative Hearings, calendaring both statutory deadlines from the day the tentative notice arrives.
Health Law Alliance's attorneys have overseen 2,000+ audits and handled 5,000+ matters, with 25+ years of experience.
If your practice has received a tentative notice of overpayment from NC Medicaid, contact us today for a free consultation through our Medicaid Audit Defense practice.
