Claims Auditing Reporting Requirements - Nebraska



Claims Auditing Reporting RequirementsThis overview covers the Claims Audit Reporting process and requirements. Reports are expected monthly and are to cover all areas and requirements specified. This specific report allows some flexibility in reporting between the MCOs as it is possible for each MCO to have unique and different internal business processes associated with the auditing of claims. Attached to this document is a sample spreadsheet to be used as a reference to the preferred format. Due to the allowed flexibility in this report it is not expected that all the MCOs’ reports to be identical but should generally follow a format similar to the example provided. MCOs are encouraged to provide additional information in line with specific claim audit methods used by the specific MCO. Once a MCO establishes their specific report then the format is to remain consistent unless the MCO notifies program staff of the change and is approved.Statistical OverviewThe audit must utilize a random sample of all processed or paid claims. If the MCO would like to use specific or weighted stratifications of the claims based on cost of the claims, services contained on the claims (i.e. behavioral health, physical health, etc.), or other reasonable stratifications, this is acceptable as long as all claims are randomly sampled and the sampling methodology is documented, including any stratifications. The sampling methodology must be provided each month along with the results of the audit. When determining sample size, use a margin of error of ±5% and a confidence level of 95%.Nebraska Medicaid Audit RequirementsThe monthly audit report must include a listing of the minimum attributes required to be tested from Nebraska Medicaid and a description on how the audits meet each testing requirement. The MCOs may and are encouraged to provide a listing of any addition testing completed by the MCO’s auditing process.The minimum testing requirements from Nebraska Medicaid are as follows:Claim data is correctly entered into the claims processing system.The claim is associated with the correct provider.Proper authorization was obtained for the service.Member eligibility on the processing date was correctly applied.The allowed payment amount agrees with the contracted rate and the terms of service the provider agreement between the MCO and the provider.Duplicate payment of the same claim did not occur.The denial reason, if applicable, was applied appropriately.Copayments were considered and applied if applicable.Patient liability was correctly identified and applied.Modifier codes were correctly applied.Other insurance was properly considered and applied if present.Proper benefit limits were applied.Proper coding including bundling and unbundling was applied.Audit SummaryThe audit summary must include the following elements and should be broken down by any stratification used by the MCOs. Total count of claimsTotal dollars billedTotal dollars paidCount of sampled claimsDollars billed on sampled claimsDollars paid on sampled claimsAmount underpaidAmount overpaidCount of sampled claims with a financial errorCount of sampled claims with a procedural errorCount of claims with any errorExplanation(s) of each error, including whether they are keying errors or errors in configuration/table maintenance of the claims processing systemDocumentation that the errors have been correctedAny other elements that may useful or may come from the sampling techniques (i.e. weighted claim count) are also encouraged to be included in this section. ................
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