Blue Cross Blue Shield of North Dakota (BCBSND) is providing additional information around the E/M Over Coding Retrospective Process. BCBSND Payment Integrity Evaluation & Management (E/M) Over Coding Concept Moving to Retrospective HCN article in September indicated this concept was moving to retrospective in October 2023. This process will be slightly different than our Clinical Chart Validation (CCV) and Retrospective Claims Accuracy (RCA) retrospective process.
Below is an overview of how this process will flow.
- Medical record requests will go out to providers once a month with a letter and spreadsheet of identified claims.
- Failure to respond will result in a claim denial and the provider forfeits any right to future payment or reconsideration.
- Providers will have 60 days to submit records via options on the letter, which includes upload to the medical records portal.
- Cotiviti will review the submitted records and send the provider and notification letter with a spreadsheet of the findings for each claim within 30 calendar days.
- Providers have an opportunity to request a reconsideration within 60 days by noting on the spreadsheet their agreement or disagreement with the determination.
- If necessary, also include additional documentation.
- Cotiviti will review the reconsideration requests and provide a reconsideration notification within 45 calendar days from receipt of the reconsideration.
- Providers can request a second level reconsideration within 60 days following the instructions provided in the reconsideration notification letter.
- Cotiviti will review the second request and the provider will receive a reconsideration notification within 45 calendar days from receipt of reconsideration.
- This outcome is final.
- If the reconsideration is upheld, BCBSND will adjust the claim to reflect the reviewed level.
- 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.
- If the provider agrees with Cotiviti’s payment integrity review determination, BCBSND will adjust the claim to reflect the reviewed level.
Note: An independent reviewer completes each level of review that was not part of the previous review.
If Providers have questions on the E/M Retrospective reviews, reach out using the phone number or email address provided on the respective letter.