CurrentFidelis CarePolicy FC.PP.008

Pre-payment and Post-payment Review (Medicare)

Defines Fidelis Care's procedures for conducting pre-payment and post-payment reviews of Medicare claims to ensure payment integrity, applicable to hospitals, physicians, and other qualified providers submitting claims for Fidelis Care Medicare products.

Policy Summary

PayerFidelis Care

PolicyPre-payment and Post-payment Review (Medicare)

Policy CodePolicy FC.PP.008

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must submit requested medical records, itemized bills, invoices, or other documentation within the RA dispute timeframe (initial 30 days, second reminder 30 days) to avoid claim denial/reduction and potential recoupment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12.1%CMS-reported improper Medicare FFS claim payment rate cited

30 daysInitial provider response time for post-payment record requests

60 daysRecoupment / appeals timeframe

Payment Review Criteria

Payment review criteria

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ALL of the following

Service is covered
Service is not excluded
Provided to an eligible member
Correct coding and billing
Rendered in a setting appropriate to the member's condition and medical needs
Not already reimbursed or the obligation of another payer
Reimbursed to the correct payee

Operational notes

Members sign an authorization for release of provider records as part of enrollment; HIPAA permits sharing of PHI between provider and plan for treatment without a separate signed release
Fidelis Care or its designee may use vendor guidelines and other contract terms to determine correct coding when applicable
Policy scope includes review of medical records for medical necessity and coding accuracy as part of Payment and Health Care Operations

Review types

Pre-payment review: review of claims prior to payment that may result in an initial determination
Post-payment review: review after adjudication that may result in no change or a revised determination (underpayment or overpayment)

Evidence and documentation

Fidelis Care may request medical records, itemized bills, invoices, or other documentation for pre-payment or post-payment review

Documentation Requests and Dispute / Appeal Rights

Documentation Required

Respond to documentation requests and follow dispute/appeal timelines

Fidelis Care (or its designee) may request medical records, itemized bills, invoices, or other substantiating documentation for pre‑payment or post‑payment review. Requests are sent by Remittance Advice for a claim denial or reduction; dispute rights commence from the date of the RA. For post‑payment reviews, an initial letter requests records within 30 days and a second reminder allows an additional 30 days; if records are not received after the second notice, recoupment may begin. If documentation is received within the applicable dispute period and supports payment, the claim will be closed; if it does not, a findings letter with a request for recoupment and appeal rights will be issued. Appeals must be submitted within 60 days of the Remittance Advice or per contract.

Requests for records are delivered by Remittance Advice for a claim denial or reduction; dispute rights begin on the RA date. [[Cited]]
Initial post‑payment record request: provider has 30 days to respond; second reminder grants another 30 days. [[Cited]]
If records are not received after the second notice, recoupment may begin. [[Cited]]
If documentation is received within the dispute period and supports payment, no further action is taken; if not, a findings letter and recoupment with appeal rights will be issued. [[Cited]]
Appeals must be submitted within 60 days of the Remittance Advice or in accordance with contract obligations. [[Cited]]

Definitions

Review / Pre-payment Review / Post-payment Review — definitions

ReviewCollection and review of information and records to ensure payments meet Medicare coverage, coding, and other requirements (CMS definition).

Pre-payment ReviewReview of claims before payment that results in an initial determination (i.e., may prevent payment or modify payment prior to adjudication).

Post-payment ReviewReview of claims after adjudication that may result in no change or a revised determination indicating an underpayment or overpayment.

Overpayment — definition and common reasons

Overpayment — definitionReimbursement greater than the amount due for covered services.

Common reason: non-covered servicesBilling for non-covered services or otherwise excessive services resulting in payment not due.

Common reason: excluded servicesPayment for services that are excluded from coverage.

Common reason: duplicate submissionDuplicate submission and subsequent payment of the same service or claim.

Common reason: inappropriate settingPayment for services furnished in a setting that was not appropriate to the patient’s medical needs and condition.

Common reason: incorrect payeePayment made to an incorrect payee.