Retrospective Audit and Medical Record Request

The Health Plan may conduct retrospective audits when paid claims data or proprietary algorithms identify potential billing errors. When potential errors are found, the Health Plan will request medical records to validate diagnosis and procedure codes billed on the claim. Once records are received, certified professional coders and registered nurses will clinically validate the documentation to ensure the medical record contains the necessary information, the diagnosis code on the claim matches the diagnosis code in the medical record, and the diagnosis billed is supported by the clinical information in the medical record. Reviews are overseen by the Health Plan Medical Director and will be completed within 30 days of receipt of medical records. After review, the Health Plan will issue an audit determination letter explaining the determination and the provider’s dispute rights. The Explanation of Payment (EOP) will include applicable explanation codes (for example: iA = Deny: medical records not received; iB/iC/iF = Pay/adjustment/reinstate after review; iE = Deny: DRG inpatient payment denied after review).

• Clinical validation performed by certified coders and RNs
• Audit determination letter with dispute instructions issued to provider
• Clinical validation completed within 30 days of receipt of records
• EOP will include explanation codes (iA, iB, iC, iE, iF)

General payment and coverage determinations

This payment policy is a guide to payment and a component of the Health Plan’s coverage and payment determinations; it does not guarantee payment. Providers must follow all terms, conditions, exclusions and limitations of the member’s coverage documents and comply with applicable state and federal requirements and plan-level administrative policies and procedures. Providers are expected to exercise professional medical judgment and are solely responsible for the medical care of members/enrollees. Prior to applying the criteria in this payment policy, providers should review any plan-specific administrative policies and verify coverage and payment with the member’s benefit documents.

• Coverage/payment determinations subject to member contract terms, state and federal law, and plan administrative policies
• This policy does not dictate clinical care — providers retain clinical judgment

Medicaid precedence and Medicare NCD/LCD review

State Medicaid provisions take precedence where they conflict with this payment policy. Providers should refer to the applicable state Medicaid manual for coverage provisions related to this policy. For Medicare members/enrollees, providers should review all applicable Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) (see CMS website) prior to applying this policy to ensure consistency with Medicare requirements.

• State Medicaid manual controls when conflicts exist between this policy and Medicaid provisions
• For Medicare members, review applicable NCDs and LCDs at http://www.cms.gov before applying this policy