Claim Audit Information for Providers

Appealing Audit Findings

HMS has confidence in the accuracy of the provider claim audits the company, conducts, gained from a long history with great results. HMS works with providers to help them understand the findings, though sometimes they disagree and want another review of the information to validate the results.

HMS supports a provider’s right to appeal claim audit findings if they believe there has been an incorrect determination. Providers receive written notification of their rights to appeal in the audit packet they receive along with a determination letter. Instructions for contacting HMS to discuss related questions are also included.

After receiving audit findings, providers have a period to request an appeal with HMS. This period may be determined by the state or by the contract between the health plan and HMS. Additional documentation can be submitted to support their point of view at this time.

When HMS receives the request, a second review of the medical record is conducted along with a review of any additional documentation provided. Additional steps are taken when audit findings are appealed. The disputed findings are reviewed by a clinical team completely distinct from those who reviewed the records during the original audit. They review any additional documentation providers send, along with the original findings.

After this second review, HMS will send the provider an appeal determination notice. This notice will provide information about the rationale used to arrive at a determination and include additional appeal options. Those can vary depending on the policy of your health plan.

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