Provider Manual Update: Special Investigations Unit (SIU) and Provider Audit changes

BCBSND is updating the Provider Manual to reflect changes made to the SIU and Provider Audit section of the manual. Implementation of changes in the audit process of the SIU and Provider Audit department is effective immediately. The updated process is outlined below:

Audit Process

1.  Claims are analyzed for appropriate submission and payment.

2.  Claims identified as potentially at risk of inappropriate submission, coding or payment are selected for additional review.

3.  Medical records and any additional information, if required, are requested from the provider or facility via certified letter with an identified due date.

a.  If the requested information is not received by the due date, all claims associated with the requested information are denied and not eligible for reconsideration.

4.  Claims, medical records and other supplied information are reviewed by a coding professional for compliance with CPT, HCPCS, ICD--CM and ICD-PCS, CPT Assistant, Coding Clinic and BCBSND policy, as well as other nationally accepted coding guidelines.

5.  If applicable, the claim may be reviewed for medical necessity by an appropriate medical professional.

6.  Results of audit findings are communicated via a letter to the provider and/or other designated contact, or via a written memorandum provided during an on-site visit. The process for correcting any identified errors is outlined in the letter or memorandum. The provider will have 30 days to correct any identified errors (if applicable), or to request a reconsideration.

Should a provider fail to respond within the 30-day timeframe, in fairness to all providers, the provider has waived any opportunity for a reconsideration or adjustment.

Reconsideration Process
If the provider disagrees with any findings, they may request a reconsideration. The reconsideration process is an opportunity for providers to request reconsideration of findings made as a result of an original audit conducted by SIU and Provider Audit. This process applies only to findings communicated by the SIU and Provider Audit department.

The provider must submit a written request. This request must include any additional information, any medical records not previously supplied and the rationale for the request within the deadline communicated in the notification of audit findings.

The request will be reviewed by a coding or medical professional not involved in the original audit. BCBSND will respond to the provider within 45 days of the receipt date of the request with a determination unless otherwise communicated.

This is the final level of reconsideration or review. No further adjustment or reconsideration of the claims will occur.

If during an audit significant errors are identified, a provider may be required to complete a self- audit. If required:

1.  The provider will be provided with a list of all claims subject to the self-audit.

2.  The provider will have the opportunity to review their medical record documentation.

a.  If the provider finds upon their review that the documentation supports the service billed, they must supply the supporting documentation in compliance with the instructions in the letter or memorandum.

b.  If, upon review, it is identified that a more appropriate code should have been billed; the provider will send the corrected claim information and submit this information along with all supporting documentation.

c.  If it is determined the service(s) should not have been billed, the provider may submit corrected information indicating such or not respond. All claims without supporting documentation supplied by the deadline will be denied as indicated in the communication.

3.  Submitted documentation will be reviewed by a coding or medical professional. This is considered a reconsideration.

a.  Claims found to be appropriately supported by the documentation will remain paid.

b.  Claims submitted for correction will be corrected if the documentation supports the requested change.

c.  Any claims or correction requests found not supported by documentation supplied will be denied and this will be communicated back to the provider. No further opportunity for reconsideration or adjustment is available.

4. Claims with no documentation supplied will be denied. No further opportunity for review of records not initially submitted is available.