Medicare AdvantageAdministrativeMedium impact
21-046 Notice About a New Payment Integrity Audit Program
Health Net·CA·Prior Authorization
Effective date
Mar 1, 2021
We identified it
Jun 20, 2026
Summary
Health Net's Cal MediConnect (Medicare-Medicaid Plan) is implementing a new payment integrity audit program starting March 2021, where Cotiviti will audit selected inpatient claims for DRG payment accuracy. Hospitals must respond to medical record requests from Cotiviti to ensure proper reimbursement, with some claims held for payment until audit completion.
Action Required
Immediately: Hospital billing teams must establish workflow to respond promptly to Cotiviti medical record requests for inpatient claims audits. Train staff to recognize Cotiviti audit letters and send only requested medical records to the address specified in each letter. Ensure DRG coding accuracy for all inpatient claims to avoid payment delays during prepay audits.