External Audit Appeal Process

Reconsideration request
Medical Director review

The External Audit Appeal Process is intended to give you an opportunity to request reconsideration of audit findings issued by the External Audit Department and to ensure we have reviewed all information relevant to the audit findings. Please note that contract terminations resulting from audit findings must follow the Provider Contract Termination Appeal Process.

1. Reconsideration Request
Upon receipt of our audit findings, you have forty-five (45) business days to review and dispute these findings before the audit becomes final. In order to appeal the findings, you must submit a written request for a reconsideration of audit findings. You will be given the address for where to send your reconsideration request with your audit findings.

The request must be received by Regence within forty-five (45) business days of your receipt of the audit findings and must include, at a minimum, the following:

• A detailed statement of the issue(s) in dispute
• At the election of the provider, notification of a request for a meeting with the panel reviewing the issue(s) in dispute
• Any documents which the provider contends supports his/her position. (Exception: Please note that all documentation required to justify your billing, including but not limited to chart notes, to be present in your files at the time of an audit. Additions to file documentation and/or the production of files that were not made available to us at the time of an audit will not be considered in connection with an appeal involving adverse audit findings. We will, however, consider your explanation as to why the documentation was not present at the time of the audit.)

If we do not receive such a reconsideration request within forty-five (45) business days of your receipt of the audit findings, the findings will be final.

The request for reconsideration will be reviewed by the manager of the External Audit Department investigators within that department, and other Regence representatives, as determined by the manager of the department (hereinafter referred to as the “Panel”). At the discretion of the Panel, a Regence Medical Director may be consulted prior to the final decision.

A meeting, prior to the Panel’s review of your request for reconsideration, can be arranged either at your office or a Regence office, as mutually convenient. You must request this meeting when submitting your request for reconsideration.

At the meeting, you may appear in person and may be accompanied by an attorney or other representative. You and your representative may make an oral statement to the Panel and respond to questions from the Panel. The purpose of this meeting is to give you an opportunity to present its position to the Panel in person.

If the Panel needs additional documentation to reach a decision, the additional documentation must be submitted within twenty (20) calendar days of the date of the written request for information, unless a written request for a reasonable extension of time is granted.

• If the requested documentation is received on time, it will be included in the request for reconsideration.
• If the documentation is not received on time, the request for reconsideration will continue and a decision will be made based on the information originally submitted.

You will be sent written notice of the decision within forty-five (45) business days following the meeting with the Panel or, if no such meeting was requested, within forty-five (45) business days of our receipt of the audit reconsideration request, not including the time waiting for additional information from you. During the period of time in which we are waiting for additional information, the appeal decision time frame is suspended until the information is received or the time to respond to the request has expired.

The decision on an audit reconsideration request is deemed final forty-five (45) business days after your receipt of the Panel’s decision, unless a timely written request for a Medical Director Review is received.

The Medical Director Review will be held no more than forty-five (45) business days following receipt of the request, not including the time in which the Company is waiting for additional information from you. The review will be conducted by a Medical Director who was not involved in an earlier review of the audit findings.

If the Medical Director needs additional documentation to reach a decision, the additional documentation must be submitted within twenty (20) calendar days of the date of the written request for information, unless a written request for a reasonable extension of time is granted.

• If the requested documentation is received on time, it will be included in the Medical Director Review.
• If the documentation is not received on time, the Medical Director Review will continue and a decision will be made based on the information originally submitted.

During the period of time in which the Company is waiting for additional information, the forty-five (45) business day clock to complete the Medical Director Review is suspended until the information is received or the time to respond to the request has expired.

You will be sent written notice of the decision within forty-five (45) business days following the Medical Director Review.

The Medical Director Review is the final step in the External Audit Appeal Process. Once a decision has been made by the Medical Director, the External Audit Appeal Process has been completed and the decision shall be deemed final. If you are not satisfied with the Company’s decision after completing the External Audit Appeal Process and want to continue to dispute the issue(s), you must initiate the appropriate process(es) as outlined in your provider contract.

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Revised February 2011