COTIVITI: FREQUENTLY ASKED QUESTIONS FOR PROVIDER INQUIRIES

1.         General Information

1.1       What is Cotiviti (“Cotiviti”)?

Cotiviti is a nationwide healthcare cost management company specializing in the review of inpatient claims.  Meridian has contracted with Cotiviti to provide inpatient DRG validation.

1.2       Where is the Cotiviti office located?

All correspondence and questions related to audits should be sent to the Cotiviti mail center at:

Cotiviti

C/O Cotiviti-6240

731 Arbor Way

Box 12017

Blue Bell, PA 19422

FAX: (801) 683-1773

1.3       If I have questions about the DRG audits, who do I call?

1.4       I did not receive a copy of the audit correspondence, or it has been misplaced.  How can I obtain a copy?

Please contact Cotiviti Provider Services at (770) 379-2322 and they will send you a copy of the correspondence.

2.         Medical Record Requests

2.1       How do I send medical records?

You may upload to our Secure Portal at www.submitrecords.com. Simply click on the “Submit Records” button and enter your password: cent12CCVC

By securely faxing to (800) 615-2809

Or by mailing the records directly to Cotiviti. Please mark the envelope “Confidential” and send to: C/O Cotiviti-6040

66 East Wadsworth Park Drive Box 12017

Draper, UT 84020

2.2       Can I fax medical records?

Yes, you may fax medical records to (800) 615-2809.  This fax is located in a HIPAA-secure location.

2.3       Will Cotiviti accept medical records via a document management clearinghouse?

Yes, if a Provider contracts with a clearinghouse that sends records to approved Business Associates, Cotiviti is authorized by Meridian to accept records from that entity.

2.6       Do I need to send the entire medical record for a case?

Cotiviti requests the minimal records needed for review:

1. DRG Coding Summary
2. Discharge Summary
3. History and Physical
4. Progress Notes and Doctor’s Orders
5. Consult Notes
6. Lab Records
7. Radiology Records
8. Emergency Department Physician Record (if applicable)
9. Physician Queries (if applicable)
10. Operative Report (if applicable)
11. Ventilator Record (if applicable)

However, if the requested information does not support reimbursement for the claim, please send any additional information necessary to support the claim as originally submitted.

2.7       What if I need more time to send the requested medical records?

If there are extenuating circumstances, please contact Cotiviti Retrieval Operations Center at (833) 931-1789, Monday to Friday from 8:00 am to 5:00 pm EST / EDT.  We will review requests for additional time on a case by case basis. 

2.8       What if I miss the deadline for submitting the medical records?

You should send the medical records to Cotiviti even if the deadline has passed, and the audit will be conducted.  Failure to submit the requested medical records may result in an administrative denial and recoupment of claim payments. 

2.9       What happens to the medical records at Cotiviti?

All Cotiviti medical record handling is HIPAA compliant and secure.  Records are scanned and archived for each audit.  The original paper copies and CDs are securely destroyed.

2.10    We would like medical record requests sent to a different name or address at our organization.  How do we request this?

All address changes must be submitted in writing via email, fax or regular mail.  Cotiviti will verify the information with Meridian and will make the correction in the Cotiviti system.

3.         Audit Determinations

3.1       What happens after Cotiviti receives our medical records?

Cotiviti reviews the claim and medical records to assess the coding and DRG assignment.  An Audit Determination Letter is mailed to the Provider after the requested medical records are received.

3.2       What coding references are used for Cotiviti audit determinations?

Cotiviti audits are based upon national correct coding standards in the ICD-10-CM/PCS Official Guidelines for Coding and Reporting. These guidelines have been approved by the organizations that make up the Cooperating Parties for ICD-10-CM/PCS: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS).  These guidelines are adhered to and future ICD-10-CM/PCS Coding Clinic publications.  Medical Necessity reviews reference InterQual® Guidelines for Acute Care: Adult and Pediatrics.

3.3       What if the claim was correctly coded?

Cotiviti sends an “Audit Determination – No Change” letter, stating that the auditor agreed with the claim as coded.  No response is required from the Provider.

3.4       When does Cotiviti inform Meridian of the audit results?

Meridian is notified of new audit results on a weekly basis.

3.5       What if I disagree with the audit determination?

If you disagree with the determination, you may submit an Informal Claim Dispute/Objection to Cotiviti, following the instructions in the letter.  Informal Claim Disputes/Objections must be submitted to Cotiviti in writing, with additional documentation to support the request. 

3.6       If a claim was not correctly coded and I agree with the audit determination, should I send a refund or corrected claim to Cotiviti?

If you agree with the audit determination, sign and return the audit determination letter to Cotiviti.  It is not necessary to send a corrected claim.  Meridian will be notified of your agreement, and will apply a payment adjustment in accordance with the audit results.

3.7       What if I do not respond to a DRG change determination?

If no response is received, Meridian assumes you agree with the audit determination and applies a payment adjustment.

3.8       We would like Audit Determinations sent to a different name or address at our organization.  How do we request this?

All address changes must be submitted in writing via email, fax or regular mail.  Cotiviti will verify the information with Meridian and make the correction in the Cotiviti system.

3.9       Can I speak to the auditor who performed the audit?

4.         Claim Disputes/Objections

4.1       Does Cotiviti handle Informal Claim Disputes/Objections?

Yes, Cotiviti handles DRG review Informal Claim Disputes/Objections on behalf of Meridian.

4.2       Can I fax a reconsideration request to Cotiviti?

Yes, you may fax your Informal Claim Dispute/Objection, with supporting documentation to (801) 683-1773.  This fax is located in a HIPAA-secure location.

4.3       What is the time frame for Claim Disputes/Objections?

Meridian’ policy requires a written Informal Claim Dispute/Objection with supporting documentation within 60 days of the Audit Determination Letter.  Cotiviti will respond with a determination within 30 days.

4.4       What happens if I do not submit a Claim Dispute/Objection within the specified time frame?

If you do not submit a Claim Dispute/Objection within the specified timeframe, Meridian assumes you agree with the audit determination and will adjust the claim payment.  If a Claim Dispute/Objection is received after the specified 60-day time limit, the original Audit Determination is upheld.

4.5       What if I disagree with the reconsideration request?

Meridian allows two cycles of Claims Disputes/Objections.