Retrospective Evaluation & Management (E/M)
Evaluation & Management (E/M) CPT codes with a level 4 and 5 are reviewed for outliers. Claims selected for review are for claims finalized the prior month. There are two different types of E/M review; Emergency Department (ED) E/M and all other E/M services. A provider can be under review for both types of E/M review.
1. Medical record requests will go out to providers once a month with a letter and spreadsheet of identified claims.
a. Failure to respond will result in a claim denial and the provider forfeits any right to future payment or reconsideration.
2. Providers will have 60 days to submit records via options on the letter, which includes upload to the medical records portal.
• A reminder letter will be sent at 45 days if records have not been sent.
3. Cotiviti reviews the submitted records and send the provider a notification letter with a spreadsheet of the findings for each claim within 30 calendar days.
4. Providers have an opportunity to request a reconsideration within 60 days by noting on the spreadsheet their agreement or disagreement with the determination.
a. If necessary, also include additional documentation.
b. Provider can request a reconsideration on any denial for no medical records during this time; records must be submitted with the reconsideration.
5. Cotiviti reviews the reconsideration requests and provides a reconsideration notification within 45 calendar days from receipt of the request.
6. Providers can request a second level reconsideration within 60 days following the instructions provided in the reconsideration notification letter.
7. Cotiviti reviews the second request and the provider will receive a reconsideration notification within 45 calendar days from receipt of reconsideration.
a. This outcome is final.
b. If the reconsideration is upheld, BCBSND adjusts the claim to reflect the review determination.
8. If a provider fails to respond at any point after the review determination has been made, the claim will be adjusted to reflect the payment integrity review determination and the provider forfeits any right to reconsideration.
9. If the provider agrees with Cotiviti’s payment integrity review determination, BCBSND adjusts the claim to reflect the reviewed level.
Note: An independent reviewer completes each level of review that was not part of the previous review.
Questions?
If Providers have questions on the E/M Retrospective reviews, reach out using the phone number or email address provided on the respective review letter.
