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 60 days using one of the methods provided in the letter. If medical records are not received within 60 days, the claim will be denied and the provider forfeits any further right to reimbursement. 

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 within 60 days 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 the audit determination to the address on the letter within 60 days of the letter date. BCBSND will adjust the claim to reflect the audit determination within 60 days of notification from Cotiviti.

Disagree with audit finding

Submit a reconsideration request, along with supporting documentation, to Cotiviti to the address provided on the audit determination letter within 60 days.

Note: Failure to respond to the audit determination letter within 60 days will result in the claim being adjusted to reflect the audit finding.

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

Reconsideration Process

The provider has 60 days from the date of the audit determination letter to request a reconsideration.

A request for reconsideration received by Cotiviti after the 60-day time limit has ended will result in the claim being adjusted to reflect the audit finding. Any further opportunity for reconsideration or 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 60 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 the audit determination to the address on the letter to Cotiviti within 60 days of the letter date. BCBSND will adjust the claim to reflect the audit determination within 60 days of notification from Cotiviti.

Disagree with determination:

Submit a second-level reconsideration request to BCBSND along with supporting documentation and a copy of the letter within within 60 days to:

Blue Cross Blue Shield of North Dakota
PO Box 1570
Fargo, ND 58107-1570

BCBSND provides a reconsideration determination within 60 days

• Overturned: No further action is required.
• Upheld: No further action is required. BCBSND will adjust the claim to reflect the final audit determination.

Note: If a reconsideration is not requested within 60 days, the claim will be adjusted to reflect the audit determination. Any further opportunity for reconsideration or payment of the claim is waived by the provider for failure to respond timely.

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.