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HDI Audits


Provider Administrative Policy

Section
Provider Information
Policy Date
December 2011
Status/Date
New/December 2011
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

HDI Audits

Blue Cross of Idaho contracts with Health Data Insights (HDI) to perform retrospective audits and identify claims that processed incorrectly.

HDI may review any claims submitted on a UB04, CMS 1500 form or equivalent 837 electronic transactions. Audits are performed within the timeframes specified in the provider contract with the 12 month restriction beginning from the date HDI issues notification of the audit or requests records. HDI is performing Automated Reviews, where no medical records are required, and Complex Reviews with a thorough review of medical records for coding validation and utilization review. When a provider is involved with a Complex Review and HDI requests records, the records need to be returned to HDI within 45 days. If you cannot deliver the records to HDI within this timeframe, please contact HDI to request a reasonable extension. HDI will inform providers of audit findings within 90 days of receipt of requested medical records.

If you disagree with HDI's findings, you have 45 calendar days from their receipt of the letter to submit additional information and request a review of the findings. HDI will conduct a review of the findings, in conjunction with any additional information provided, within 60 calendar days. If you don't submit a review of findings request within 45 days, Blue Cross of Idaho will reprocess the claims in accordance with the HDI audit findings.

There are specific processes in place for providers that disagree with an audit finding. The first step is to let HDI know you are challenging the audit findings by contacting HDI at the phone number and/or address noted in the HDI letter. HDI will complete a thorough reconsideration with any additional information provided and let the provider know of the decision. If HDI agrees with the provider, we will take no further action on the claim. If HDI continues to support their audit findings, the provider will have the opportunity to follow Blue Cross of Idaho's complete appeal process, though a provider must initiate the First Level Appeal within 30 days of HDI's decision to uphold their audit findings.

Please remember to direct the first request for reconsideration to HDI>

Health Data Insights
7501 Trinity Peak
Mailstop#24-M
Las Vegas, NV 89128
Phone: 866-875-1749
Fax: 702-240-5518


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