Payment Integrity Process
What is a Payment Integrity Program?
Payment Integrity Programs review claims with the intent of validating the appropriateness of the rendered services and payments made for those services. Iowa Total Care may contract the services of vendors with domain expertise to manage the review process for our payment integrity programs. These third parties utilize reviewers with varied experience from across the industry, including registered nurses, coding specialists, claims operations experts, network managers, quality experts, contract managers and more. These programs are in accordance with contracts that exists between you and the Health Plan.
Payment Integrity Program Process
1. Post-payment claims data is reviewed for payment accuracy by Iowa Total Care or 3rd party vendors
a. Underpayments will be adjusted and paid via your typical payment method with an adjusted EOP.
b. Overpayments will be processed through notification of recovery/initial request
2. Initial request
a. Should medical records be required, payment integrity program vendors may request specific documentation. In the request, the vendor will specify the timeframe for the requested documentation along with instructions on how and where to send the information.
b. If medical records are not required or the review of medical records received confirm payment inaccuracy, a notice of overpayment will be sent. Details of the findings will be provided for your review within the notification.
i. If you agree with the findings, direction will be included on how to make repayment or overpayments will be taken from future claim submissions.
ii. If you disagree with these findings, you will have the opportunity to appeal the results.
3. Appeal process
a. A payment integrity program appeal is a request for reconsideration of the determination resulting from a claim payment accuracy review. All appeals relating to payment integrity programs must be submitted in writing and include all necessary documentation. Appeals must be sent directly to the vendor; submission instructions will be supplied in the determination letter. The appeal must be received within 30 days from the date on the determination letter.
b. All submitted appeals should include as much information as possible so Iowa Total Care or the 3rd party vendor can understand why the reconsideration determination was in error.
c. We will work to resolve all claim payment appeals within 30 calendar days of receipt of all information.
d. A determination letter from Iowa Total Care or the 3rd party vendor will be issued detailing the appeal decision including statement of and reason for action taken.
e. If the final decision results in a claim adjustment, payment and EOPs will be sent to you.