A Guide to the Prepayment Claims Review Program

Date: 03/03/22

Why are you starting up this new audit program?

Sunshine Health is conducting this pre-payment, routine claim review for Marketplace (Ambetter) and Medicare (Wellcare by Allwell) members to confirm the billing accuracy/appropriateness of the claims submitted. Sunshine Health routinely reviews billed claims to ensure that billing codes and practices used in claim submission are correct and appropriately documented, and that Sunshine Health is paying healthcare providers appropriately.

Why was my claim selected for medical record review?

There were potential billing inaccuracies detected in the claim as billed, so in order to ensure the claim was coded and documented appropriately, we are performing a medical record review by CPC certified coders before the claim is paid. Please note this is not a medical necessity review. Only a small percentage of a provider’s submitted claims will be selected for review, in most cases.

What codes/services are being audited in this new program?

All codes/services billed on professional claim forms will be subject to this prepayment billing review if billing inaccuracies are detected.

What happens if my claim gets selected for a medical record review?

You will receive an explanation code on your EOP noting medical records are required.  You will also receive a letter from Cotiviti listing the specific claims requiring medical records.

Please send the medical records documentation using one of the following methods:

• Secure provider upload portal (password: CPRrca37)
• Secure fax: 1-800-391-5365

Why audit my claim before payment, and not after payment?

It is more desirable to pay the claim correctly, the first time. Many providers find it inconvenient to receive a request for a refund or offset against future claims if an overpayment was made. Procedures involved in accurately and timely compensating providers for their services have evolved as reimbursement methodologies and complexities have expanded. Historically, claim adjudication has only focused on ensuring eligibility and conducting basic administrative and code editing. In order to proactively identify potential billing inaccuracies, Sunshine Health has enhanced its adjudication process to also include an analysis of the claim’s specific charges in comparison with the medical records.

What coding expertise does the Cotiviti reviewers have to ensure accurate decision making?

All reviews are completed by either a CPC certified coder, or a nurse coder with a CPC certification. Supervisory staff and/or a medical director conducts quality reviews before the review determinations are finalized.

How long will it take to receive my payment after I send in the medical records?

You will receive payment according to Sunshine Health prompt payment guidelines once the required information is received.

What information will I receive if my claim is denied?

You will receive an explanation code on your EOP with the reason for the denial.  You will also receive a review determination letter explaining the denial, and a listing of the information to appeal should you disagree with the audit finding.

Can I rebill to receive payment if my claim was denied?

In most cases, the review process is expedited by following the appeal process outlined in the review determination letter, instead of re-billing the claim. Please reach out to your Provider Relations Representative if you have questions related to rebilling your claim.

Can I appeal/dispute the denial with additional information if I disagree with the findings?

Yes, you may send in your appeal/dispute form with the additional information you have to supply to Cotiviti.  The information on how/where to appeal will be noted on the review determination letter.

• Appeal/Dispute requests should be submitted to:
  • Centene_Payment_Accuracy@Cotiviti.com
  • Fax: 1-866-816-5401

• Required information for dispute submission:
  • Name, address and phone number of serving provider
  • TIN and NPI
  • Dispute justification with supporting documentation

Can I appeal/dispute Cotiviti’s appeal denial determination?

Yes, you can appeal/dispute Cotiviti’s appeal denial determination.  You can send your additional information you have to supply to:

Ambetter from Sunshine Health
P.O. Box 5010
Farmington, MO 63640

**Please note this address should only be used AFTER you have initially appealed to the Cotiviti address above.

The information on how/where to appeal will also be noted on the review determination letter.

How long is the dispute review timeframe?

Sunshine Health processes appeal/disputes within 60 days.

What should I do to correct future claim billing, so I don’t receive these requests for medical records in the future?

Please review and follow the billing policy references indicated in the denial rationale on the review determination letter, so you can identify deficiencies and proactively correct them. You can also refer to your Provider Portal tools and resources like the Provider Manual, Payment Policies, and other provider resources. By improving your billing and adopting best coding practices, you will stay in compliance with industry standard guidelines/regulations and you will ensure accurate reimbursement for your claims. If you still have questions, you may call or e-mail your Provider Relations Representative. They will direct you to the proper coding specialists at Sunshine Health to discuss the actual audit finding with you and direct you in how to correct future claim billing.

For any additional questions regarding this program, please send an email to our Payment Integrity  team at Prepay_Cotiviti_FWA_Validation@Centene.com.