We may review paid claims to help ensure payment integrity. If reviewing all medical records for a procedure would burden you, we may select a statistically valid random sample (SVRS) or smaller subset of the SVRS. This gives an estimate of the proportion of claims that we paid in error. The estimated proportion, or error rate, can be projected across all claims to determine overpayment. You may appeal the initial findings. You must supply all requested medical records. Failure to do so may result in an audit failure denial of the entire SVRS and all claims submitted within the review.
Please handle overpayment disagreements as outlined in this guide and in your Agreement.
Provider audits may be a phone call, on-site visit, internal claims review, client-directed/regulatory investigation and/or compliance reviews. We ask that you provide us, or our designee, during normal business hours, access to examine, audit, scan and copy any and all records necessary to determine compliance.
In general, we notify you in writing no less than two weeks of a pending in-depth audit involving claims review. However, if we suspect that there is fraudulent activity we may conduct an on-site audit without notice. If you refuse to allow access to your facilities, we reserve the right to recover the full amount paid or due to you.