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July 2017
Medicare Plus BlueSM PPO skilled nursing facility, home health care second-pass claim audits starting
HMS (formerly Health Data Insights) and SCIO Health Analytics®, two Blue Cross and Blue Shield of Michigan vendors, will start a onetime second-pass audit for skilled nursing facility and home health care provider paid claims. This is the second time the vendor is choosing cases from a specific data period since the first audit was limited to a certain number of claims.
The audits will:
- Begin with April 2017 data and look back two years.
- Use a look-back date that’s based on the date the claim was paid.
- Require providers to submit medical charts.
The medical chart request letters will be staggered, going out over a three-month period.
For 2015 paid claims, the vendors will focus on CMS compliance requirements. The focus on 2016 paid claims will be on both compliance and medical necessity.
Audit finding letters will include information on how to request an appeal, if necessary.
About HMS and SCIO
Through its vendors, HMS and SCIO, Blue Cross conducts retrospective provider audits to:
- Detect, prevent and correct fraud, waste and abuse.
- Facilitate accurate claim payment.
- Check that the most appropriate, cost-effective services and supplies were provided.
- Make sure that medical records and documentation verify the setting or level of service that was provided to the patient.
Got questions?
Call your Blue Cross provider consultant.
During an audit, if you need to speak to a vendor representative:
- Skilled nursing facilities can call HMS at 1-866-875-1749, Monday through Friday, 11 a.m. to 8 p.m. Eastern time.
- Home health care providers can call SCIO at 1-866-628-3488.
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