21-138 Notice About a New Payment Integrity Audit Program
Date: 02/09/21
This information applies to Hospitals.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.
Send requested medical records to help ensure your DRG payment is correct
A new audit program will begin in April 2021. Selected inpatient claims and their related medical records will be audited as part of the payment integrity program. The audit ensures diagnosis related group (DRG) payments are applied using nationally correct coding standards.
Cotiviti may contact you
Health Net, on behalf of CalViva Health, has contracted with Cotiviti to help with this effort. If you have an inpatient claim selected for audit, you will receive a letter from Cotiviti listing the claim information and the medical records needed. You may receive the request before the claim is paid, or after a payment is made.
- Send in only the requested medical records to the address noted in the letter.
- An inpatient claim selected for prepay audit will be contested for medical records. Payment is made after the medical records are received and the audit is complete.
Claims reimbursement
As a reminder, payments to contracted providers for covered services are based on contract provisions supplemented by fee schedules, payment policies and coding methodologies.
Additional information
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 1-888-893-1569.