How to appeal Cotiviti’s DRG cross-claim clinical reviews

Cotiviti, an independent company that provides claim reviews for Blue Cross Blue Shield of Michigan and Blue Care Network, is conducting diagnosis-related group cross-claim clinical reviews, or CCCRs, for Medicare Plus Blue℠ and BCN Advantage℠ inpatient claims. The reviews will focus on the member's episode of care as explained in a March 2024 article in The Record.

Initial review and notification

Cotiviti selects claims to review without medical records. If Cotiviti identifies an adjustment opportunity, it will notify health care providers by mail. If you disagree with Cotiviti's decision, you have 50 calendar days to submit a written appeal request.

Appeals process

Submit written appeal requests through Cotiviti's Provider Connection Portal or refer to your audit finding letter for the mail or fax addresses.

• First-level reconsideration: Submit a written request within 50 days of the date on your audit finding letter. Include all relevant medical records with the first-level appeal request coversheet. Don’t submit medical records separately.
• Second-level appeal: If necessary, submit a written request to Cotiviti within 20 days after the first-level appeal results for an external review by Physicians Review Organization, an accredited independent medical review organization.

If you have questions, contact Cotiviti Provider Relations at 770-379-2009 from 8 a.m. to 5 p.m. Eastern time, Monday through Friday.