Maryland Medicaid: Prepare for medical record and billing audit

Ensure your documentation is complete, accurate and aligned with billing to avoid audit findings, denials or recoupments

Between August and November each year, Maryland Department of Health conducts encounter data validation audits of medical records against claims to ensure accuracy and compliance.

What you need to know

• The state will mail letters in advance of the audit to billing providers of managed care organizations  requesting medical records of selected claims
• The state’s auditor, Qlarant, will contact providers by phone or fax with follow-up requests, as needed 
• Records are reviewed against the corresponding claims to match procedure, diagnosis and revenue codes

What you need to do

• Maintain complete, accurate and organized medical records in paper or electronic format
• Ensure records are legible and reflect all services rendered
• Submit records on time, as defined by the state. Urgent requests may require a 48-hour turnaround.

Claim submission best practices

To help avoid claim audit findings, denials and payment recoupments, ensure your claims fully align with the members’ medical records.

• Include all documentation required to support billed services
• Use correct and appropriate diagnosis and procedure codes
• Verify the amount billed corresponds to the services provided

Supporting resources

For more information on medical record requirements, billing practices and audit expectations, review the Maryland Provider Care Manual or visit Claims, billing and payments.