Claims Denials
Provider Type
- Participating Physician Groups (PPG)
- Hospitals
The Delegation Oversight auditors review claim denial letters used by participating physician groups (PPGs) and other participating providers to ensure that notification letters to providers and members comply with accuracy and timeliness requirements. Providers may only send a denial notice to a member when the member is liable.
Refer to the Denial Notification topic for the requirements regarding timeliness and letter components.
Claim Audit Check Cashing Requirement
The claims audit check cashing turnaround time requirement for checks mailed by the plan's hospitals and delegated PPGs to their participating and non-participating providers is 14 calendar days.
Seventy percent of checks mailed by the plan's hospitals and delegated PPGs to their participating and non-participating providers must clear within 14 calendar days of the date the check was mailed.