Rev. January 2020
Provider Self-Audit Attestation
The Alaska Department of Health and Social Services requires all Medicaid providers to conduct an internal self-
audit once every two years and repay all identified overpayments (AS 47.05.235; 7 AAC 160.115).
Following each self-audit, providers must sign and submit to the department this Provider Self-Audit Attestation.
• Providers reimbursed more than $30,000 annually, as determined by the provider’s IRS Form 1099, must
complete and submit a self-audit report to the department.
• Providers reimbursed less than $30,000 but more than $10,000 annually, as determined by the provider’s IRS
Form 1099, must complete a self-audit but are not required to submit a self-audit report to the department.
Providers must have the report available for review by the department upon request.
• Providers reimbursed less than $10,000 annually are required to complete only this attestation.
Submit attestations and reports (if applicable) to DHSS, Medicaid Program Integrity, 3601 C Street, Suite 902,
Anchorage, AK 99503, or QAPIProgramIntegrity@alaska.gov.
This Provider Self-Audit Attestation form constitutes a medical assistance record under 7 AAC 105.230(a); this
signed and dated form must be maintained as verification that the provider timely completed the self-audit of
applicable Medicaid billing by the provider.
Provider ID* Tax ID Calendar Year
Enrolled Provider Name Title
Enrolled Provider Signature Date
I _______________________acknowledge and affirm under penalty of unsworn falsification (AS 11.56.210) that
(i) I have prepared, or have caused to be prepared a Medicaid provider self-audit in accordance with the
applicable Alaska Statutes and Regulations; (ii) the information in the self-audit is true, correct, complete, and in
compliance with the applicable Alaska Statutes and Regulations; (iii) I have the authority to verify the accuracy of
this self-audit on behalf of my organization and to bind my organization to the results of the self-audit; (iv) I am
familiar with the applicable Alaska Statutes and Regulations governing the self-audit; (v) corrective actions are
being implemented for all deficiencies identified in the self-audit; and (vi) all overpayments identified by the self-
audit will be repaid in accordance with 7 AAC 160.115. Knowingly making a false statement on a medical
assistance record constitutes medical assistance fraud in accordance with AS 47.05.210(a)(5).
* If multiple Provider IDs are associated with this tax ID, attach separate schedule and identify all provider IDs covered by the self-audit.
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