MedicaidAdministrativeMedium impact
21-138 Notice About a New Payment Integrity Audit Program
Health Net·CA·Prior Authorization
Effective date
Apr 1, 2021
We identified it
Jun 20, 2026
Summary
Health Net CalViva Health has implemented a new payment integrity audit program starting April 2021 where Cotiviti will audit selected inpatient claims to ensure correct DRG payment coding. Hospitals in Fresno, Kings, and Madera counties must respond to medical record requests from Cotiviti for selected inpatient claims, which may be audited before or after payment.
Action Required
Immediately: Hospital billing teams must establish process to respond promptly to Cotiviti medical record requests for inpatient DRG audits. Monitor for audit letters listing required medical records and claim information. Send only requested records to address specified in letter. Note that prepay audited claims will be held until records are received and audit completed.