We may review paid claims to help ensure payment integrity. If reviewing all medical records for a procedure would burden you, we may select a statistically valid random sample (SVRS) or smaller subset of the SVRS. This gives an estimate of the proportion of claims we paid in error. The estimated proportion, or error rate, can be projected across all claims to determine overpayment. You may appeal the initial findings. You must supply all requested medical records. Failure to do so may result in a failure of the entire SVRS and all claims submitted within the review.
You must handle overpayment disagreements as outlined in this guide and in your Agreement.
Provider claim reviews may be a phone call, on-site visit, internal claims review, client-directed/regulatory investigation and/or compliance reviews. We ask that you provide us, or our designee, during normal business hours, access to examine, review, scan and copy any and all records necessary to determine compliance.
If you refuse to allow access to your facilities, we reserve the right to recover the full amount paid or due to you.