Clinical Chart Validation (CCV) Process Flow

Medical Records Request

1. Cotiviti reviews finalized claims and identifies claims to audit.

2. Provider receives a medical records request letter from Cotiviti on behalf of BCBSND. All medical record requests will come via letter from Cotiviti.
    Medical Records Request Sample.pdf *

3. Submit medical records within 45 days using one of the following methods:

• Provider portal
• Fax: 800-355-6234
• Remote EMR access: Call 833-931-1789 to make arrangements
• Mail:
  Cotiviti 6750
  66 East Wadsworth Park Drive
  Box 12017
  Draper, UT 84020

Note: Cotiviti and BCBSND will not reimburse the cost for requests of medical records or expedited mailing services.

For questions about the medical record retrieval process, please contact Cotiviti Retrieval Operations Center at 833-931-1789.

Audit Determination

Once Cotiviti has completed their review of medical records, they will send an Audit Determination letter with one of the following outcomes:

No Change:

Cotiviti agrees with the claim submission. No further action is required.
Cotiviti Audit Determination: No Change.pdf *

Change:

Cotiviti disagrees with claim submission and provides the audited results.
Cotiviti Audit Determination: Change.pdf *

Agree with audit finding

Sign and return a claim adjustment form and a copy of the letter to Cotiviti within 45 days from the date on the audit determination letter.

Cotiviti 6750
66 East Wadsworth Park Drive
Box 12017
Draper, UT 84020
Fax: 203-642-7678

Disagree with audit finding

Submit request to Cotiviti along with supporting documentation within 45 days.

Cotiviti 6750
66 East Wadsworth Park Drive
Box 12017
Draper, UT 84020
Fax: 203-642-7678

Note: If a claim adjustment (change to claim agreement received by Cotiviti) exceeds the 45-day time limit, the claim will result in a denial. Any further opportunity for payment of the claim is waived by the provider for failure to respond timely.

For questions on your audit determination, please call Cotiviti at 770-379-2169.

Reconsideration Process

The provider has 45 days from the date of the audit determination letter to request a reconsideration.

A request for reconsideration received by Cotiviti after the 45-day time limit has ended will result in a claim denial. Any further opportunity for payment of the claim is waived by the provider for failure to respond timely.

Cotiviti will review the reconsideration request along with the supporting documentation and send a reconsideration determination within 45 days from the receipt date of the request.

Reconsideration Overturned

Cotiviti agrees with the claim submission. No further action is required.
Cotiviti Reconsideration Overturned.pdf *

Reconsideration Upheld or a New Determination

Cotiviti Reconsideration Upheld.pdf *
Cotiviti Reconsideration New Determination.pdf *

Agree with determination:

Sign and return a claim adjustment form and a copy of the letter to Cotiviti within 45 days.

Cotiviti 6750
66 East Wadsworth Park Drive
Box 12017
Draper, UT 84020
Fax: 203-642-7678

Disagree with determination:

Submit a second-level reconsideration request to BCBSND along with supporting documentation within 45 days to:

Manager of SIU/Provider Audit
Blue Cross Blue Shield of North Dakota
4510 13th Avenue S
Fargo, ND 58121

BCBSND provides a reconsideration determination within 45 days

• Overturned: No further action is required.
• Upheld: Submit a signed agreement, claim adjustment form and a copy of the final audit determination within 45 days.

Manager of SIU/Provider Audit
Blue Cross Blue Shield of North Dakota
4510 13th Avenue S
Fargo, ND 58121

Note: If a reconsideration is not requested within 45 days, rights are forfeited. The claim will be adjusted to deny, and you will receive notification on your electronic remittance advice within 45 days.

For questions on your reconsideration notice, please call Cotiviti at 770-379-2169.

*Sample letter verbiage is subject to change. These images are just samples of the letters you or your administration may see.