Upcoming Post-payment Review Process Changes for Group and Individual Plans

Before implementation date (TBD): (1) Billing and clinical teams must establish internal processes to track medical records requests from Cotiviti Inc. and ensure 45-calendar-day submission deadlines are met. (2) Update billing system workflows to flag claims for group numbers 61, 62, 64, and 65 that involve short-stay hospital admissions, DRG-based billing, or readmissions as potentially subject to post-payment review. (3) Designate a point person to receive and manage Cotiviti correspondence and coordinate medical records retrieval. (4) Develop appeal procedures documenting both first-level appeals to Cotiviti and second-level appeals to BlueCross with all supporting documentation. (5) Monitor provider relations communications for the definitive implementation date and adjust staff training accordingly. Failure to submit requested records within 45 days may result in claim adjustments or refunds without provider input. Establish tracking system immediately to prevent missed deadlines once implementation begins.