CurrentSharp-Health-PlanPolicy N/A

Internal Claims Audit Policy

Governs Sharp Health Plan's procedures for conducting internal audits of paid, late, denied, and PDR claims to ensure regulatory compliance; affects Claims Research, Customer Care, Network Development, Provider Contracts and Regulatory Affairs, and related staff performing audits.

Policy Summary

PayerSharp-Health-Plan

PolicyInternal Claims Audit Policy

Policy CodePolicy N/A

Change TypeTechnical/Operational (no material coverage changes)

Effective Date

Next Review Date

Key ActionSelect 50 claims at random in each category (Paid, Late, Denied, PDR) and review an initial 25; stop the audit early if the first 25 are ≥95% compliant.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4claim categories audited (Paid, Late, Denied, PDR)

50claims selected per category

25initial claims reviewed per category

45HMO timeliness (business days)

30POS timeliness (business days)

Audit Selection and Criteria

Policy Summary

PayerSharp-Health-Plan

PolicyInternal Claims Audit Policy

Policy CodePolicy N/A

Change TypeTechnical/Operational (no material coverage changes)

Effective Date

Next Review Date

Key ActionSelect 50 claims at random in each category (Paid, Late, Denied, PDR) and review an initial 25; stop the audit early if the first 25 are ≥95% compliant.

SourceLink

On This Page

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inv-01: Audit procedures and criteria

Audit selection and review stop-rule applied to each claim category.

ALL of the following

Use an Answers Plus query to generate a listing of all claims processed by SHP during the audit period and include all elements listed in Attachment A.
Select 50 claims at random for each of the four claim categories: Paid, Late, Denied, and PDR.
From the 50 selected claims in each category, review an initial sample of 25 claims; if the first 25 are >=95% compliant with all audit criteria, the audit for that category may be ended early.

ALL of the following

Confirm Date of Receipt (DOR) is entered into the system correctly.
Confirm number of days to enter claim into system (acknowledgement) meets regulatory requirements.

ALL of the following

Payment: Confirm the claim was paid in accordance with the provider contract.
Timeliness: Confirm days between DOR and Date of Payment (DOP) are within thresholds: HMO ≤ 45 business days; POS ≤ 30 business days.
Interest and penalties: If claims are not reimbursed within the above timeframes, confirm interest and penalties were paid per Title 28 CCR Section 1300.71 (AB 1455).
Interest calculation: Confirm appropriate interest and penalties were calculated and paid when applicable.
Medical records request: Confirm compliance with Rule 1300.71(a)(8)(H) and (I) regarding medical record requests.
Rescinded or changed authorized service: Confirm compliance with Rule 1300.71(a)(8)(T).

ALL of the following

Appropriateness: Ensure the claim was denied appropriately based on the denied disposition code.
Filing deadline: Confirm compliance with contracted and regulatory timely filing guidelines.
Claim forwarding: Confirm compliance with timeliness guidelines for redirected emergency service and care claims.
Written explanation: Confirm an appropriate written explanation for denied, adjusted, or contested claims was sent to the provider.
Rescinded or changed authorized service: Confirm compliance with Rule 1300.71(a)(8)(T).

ALL of the following

PDR Date of Receipt: Confirm the DOR is entered correctly per Rule 1300.71.38(a)(3).
PDR acknowledgement: Confirm acknowledgement complies with Rule 1300.71.38(e).
PDR turnaround time: Confirm the PDR process time complies with Rule 1300.71.38(f).
Claim payment and written determination: Confirm compliance with Rule 1300.71.38(g) including issuance of written determination letter.
Interest calculation: Confirm interest and penalties were calculated and paid when applicable for PDR outcomes.

ALL of the following

Confirm written determinations and explanations were sent to providers for denied, adjusted, contested claims and for PDR outcomes per applicable CCR rules.

ALL of the following

Ensure denial reason codes (including filing-deadline reasons) are captured and reviewed as part of appropriateness assessment.

ALL of the following

Paid, Late, Denied, and PDR claims are the four audited categories and DOR/DOP definitions apply when verifying timeliness.

Provider Notices and Remedies

Denial Risk

Provider notices for denials and PDRs — requirements

Providers must receive written notices for any denied, adjusted, or contested claim and for Provider Dispute Resolution (PDR) outcomes. Sharp-Health-Plan will send timely written determinations that explain the reason(s) for denial or adjustment, the clinical or contractual basis, the specific disposition code where applicable, and any appeal or filing deadlines. For PDRs, providers will receive acknowledgements, written determination letters, and notice of payment or denial consistent with regulatory timelines.

Written Explanation: A written explanation must be sent to the provider for any denied, adjusted, or contested claim (including contested claim outcomes).
PDR Acknowledgement: Providers will receive a PDR Date of Receipt acknowledgement entered into the system per Rule 1300.71.38(a)(3).
PDR Turnaround & Determination: PDRs will be processed within the turnaround times required by Rule 1300.71.38(f) and providers will receive a written determination letter as required by Rule 1300.71.38(g).
Filing Deadlines & Appeals: Notices will include applicable timely filing deadlines and instructions for filing appeals or disputes.
Interest & Penalties: When claims exceed regulatory timeframes, interest and penalties will be paid to the provider in accordance with Title 28 CCR Section 1300.71 (AB 1455); written notices will reflect any such payments where applicable.
Redirected Emergency Claims: Notices and forwarding for redirected emergency service and care claims will comply with required timeliness guidelines.

Note

Interest and penalty payment for late claims — provider remedy and payment obligations

Providers may pursue remedies when Sharp-Health-Plan fails to meet regulatory timeframes. If claims are not reimbursed within the timeframes specified (45 business days for HMO claims; 30 business days for POS claims), interest and penalties will be calculated and paid to the provider according to Title 28 CCR Section 1300.71. Audits will verify that interest calculations and payments were made when applicable.

Timeliness Standard: 45 business days (HMO) and 30 business days (POS) measured from Date of Receipt to Date of Payment.
Interest Calculation & Payment: Confirm appropriate interest and penalties were paid when applicable per Section 1300.71.
Audit Verification: Audits will confirm Date of Receipt entry, days-to-enter into claim system, timeliness from DOR to DOP, and correct payment of interest/penalties.
Medical Record & Service Changes: Audits will also confirm compliance with Rule 1300.71(a)(8)(H),(I) for medical record requests and (T) for rescinded or changed authorized services.

Key Terms

Paid Claims

DefinitionClaims paid by Sharp Health Plan within the regulatory specified timeframes.

Verification stepsConfirm payment was made in accordance with the provider contract and that Date of Payment (DOP) falls within applicable timeliness thresholds.

Audit evidenceAudit must document Amount Paid and Date of Payment consistent with Sharp Health Plan Claims Data Audit Report Requirements.

Late Claims

DefinitionClaims paid by Sharp Health Plan outside of regulatory outlined timeframes.

ConsequencesLate payments may require payment of interest and penalties per Title 28 CCR Section 1300.71 (AB 1455).

Audit checkConfirm Interest Calculation and that appropriate interest and penalties were paid when applicable.

Denied Claims

DefinitionClaims denied for payment by Sharp Health Plan.

Audit criteriaEnsure denial appropriateness based on denied disposition code and confirm Filing Deadline compliance.

Provider notificationConfirm a written explanation for any denied, adjusted, or contested claim was sent to the provider.

PDR Claims

DefinitionClaims that were reviewed and adjudicated based on the DMHC outlined Provider Dispute Resolution (PDR) mechanism.

Audit focusConfirm PDR Date of Receipt entry, acknowledgement, turnaround time, payment outcome and written determination per Rule 1300.71.38.

Interest requirementVerify interest calculation and payment when PDR adjudication requires payment per applicable regulations.

Answers Plus

System nameAnswers Plus — The Sharp Health Plan data warehouse system used to generate audit reports.

UsageUse an Answers Plus query to list all claims processed during the audit period and select claims for sampling and review.

Report fieldsAnswers Plus reports must include required audit fields such as Claim Number, Amount Paid, Date of Payment, Denied Code, Line of Business, Provider Name, and Service Type.

DOR / DOP

DOR (Date of Receipt)The working day when a claim, by physical or electronic means, is first delivered to Sharp Health Plan; used to start timeliness calculations.

DOP (Date of Payment)The date on which the payment was issued to a provider or the date of postmark/electronic mark indicating electronic transmission or deposit; used to determine compliance with timeliness thresholds.

Audit usageAuditors must confirm DOR is entered correctly and calculate days between DOR and DOP to assess timeliness per HMO/POS thresholds.

OpenPayer

Internal Claims Audit Policy

Audit Selection and Criteria

Coding and Timeliness Standards

Provider Notices and Remedies

Key Terms