• Applicable to all states except NC

Hospital Audit Services - Chapter 10, 2020 UnitedHealthcare Administrative Guide

Hospital Audit Services

Facility audits help to identify billing and coding errors. They include a thorough review of critical claim elements, such as medical records and itemized bills. We conduct the audits offsite, unless contractual obligations state otherwise.

Audit Findings

When an audit is completed, the auditor notifies the hospital of the findings. We provide the hospital representative with a copy of the audit findings.

Post-audit Procedures

  • Refund Remittance – Following an overpayment request, the hospital remits the amount of the overpayment within 30 calendar days of receipt of the refund request, or as required by state or federal law.
  • Audit Findings – If the hospital disagrees with the findings, they submit notification of the disagreement within 30 calendar days of receipt of the audit findings per the terms outlined in our overpayment notification letter. The notification must clearly identify the items in which you disagree and include any relevant documentation to support your position.
  • Disagreement Resolution – We respond to audit findings in writing. Time frame varies by state and vendor. For continued resolution, refer to the Claim Reconsideration and Appeals Process in Chapter 9.
  • Offsets – When we issue a refund request in connection with an audit, we recoup or offset the identified overpayment, and/or disallowed charge amounts after 35 calendar days from the date of the refund request, except when the hospital:
    • Has given us the amount due within the 35 calendar day repayment period
    • Has provided written notification of its disagreement with the audit findings within the 35 calendar day repayment period
    • Your Agreement or state law says otherwise