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Regence Blue Cross Blue Shield of Oregon
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Claims and Billing - For Providers  - Receiving Payment
Provider Audits

Regence audits the billing of its participating physicians, dentists, other health care professionals and facilities. While many of our audits are to determine whether we have been appropriately billed, we also audit to determine:

  • Medical necessity
  • Proper utilization
  • Coverage of services
  • Appropriateness of services
  • Accuracy of claims submitted

Audits are also done in the case of abusive billing practices or to determine the possibility of fraud. Trained auditors review all areas of medical services, including:

  • Hospitals
  • Physicians
  • Pharmacies
  • Practitioners
  • Laboratories
  • Ancillary health care providers
  • Suppliers of durable medical equipment and supplies

All audits comply with the laws, statutes and regulations pertaining to the confidentiality of member records. Information is not disclosed, except to accomplish the audit or report findings/conclusions where appropriate and necessary.

Audits are conducted in the offices of our providers and occur at a mutually agreed date and time within the timeframe specified in your agreement with us.

In the event of an audit, please allow sufficient space within your office to review records and copy those records relevant to the scope of the audit. The audit may include charges to members not covered by agreements with Regence. However, the provider may obscure or remove these names from the billing records being audited.

Copies of relevant records may be removed from your office for the purpose of comparison with claims that have been submitted to Regence. Our staff will conduct this review at our offices. We will protect the confidential nature of the member records. We will destroy all copies of documentation acquired from an external audit review in a manner that will protect the integrity of confidential information and abide by all laws, statutes and regulatory requirements concerning the protection of confidential medical health care information once the audit file is closed and the need to retain any such information no longer exists. Regence, as a responsible health care services contractor, is obligated to ensure the integrity of claims submittal and its reimbursement system. Therefore, it is our policy to exercise our contractual ability to audit documentation in support of claims submitted on behalf of our members.

Additional audit provision information is available in your Regence agreement.


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What you should know about Post-Payment Audits
Our Reimbursement Integrity team is dedicated to ensuring that claims have been paid correctly by performing post-payment audits. Overpaying or underpaying for services rendered is a disservice to both our providers and our members.

Audit tips

Follow instructions in the request letter
Submit the requested information electronically
Submit all information prior to the due date indicated

Upcoming audits

Skilled Nursing Facility audit to begin

Our upcoming Skilled Nursing Facility (SNF) audit will retrospectively review SNF claims to:

  • Assess compliance with Minimum Data Set (MDS) assessment requirements
  • Validate accuracy of Resource Utilization Group (RUG) coding
  • Ensure utilization of services in accordance with CMS guidelines.

At this time, this audit only applies to Medicare Advantage claims. An audit of commercial claims will be performed later this year.

Please note:

  • It is the fundamental responsibility of every provider to bill and code accurately. This review will be applied to the complete span of care (from admission to discharge comprises one span of care).
  • The Resident Assessment Instrument (RAI) manual governs submission of MDS assessments for SNF patients.
  • This is a review of the services provided as defined in Chapter 8 of the Medicare Benefit Policy Manual. There is no member liability.

Ventral Hernia Repair Code Pairs
The purpose of this audit is to determine if support exists for CPT codes 49560, 49561, 49565, and 49566 to be billed with CPT codes 15734 and 15734 with a Modifier -59.

  • Main codes: CPT 49560, 49561, 49565, and 49566
  • Denied code: CPT 15734, 15734-59

Please note: If we request records be submitted from your office, please submit them within the 45 day timeframe noted on the letter received.

Chiropractic Code Bundling
The purpose of this audit is to determine if support exists for CPT codes 98941 and 98942 to be billed with CPT code 97140.

  • Main codes: CPT 98941, 98942
  • Denied code: CPT 97140

Please note: If we request records be submitted from your office, please submit them within the 45 day timeframe noted on the letter received.

Lap Hernia Repair Code Pairs
The purpose of this audit is to determine if support exists for CPT codes 43281 and 43282 to be billed with CPT codes 43279, 43280, 43644, 43645, 43770, 43771, 43773 and 43775.

  • Main codes: CPT 43279, 43280, 43644, 43645, 43770, 43771, 43773, and 43775
  • Denied codes: CPT 43281, 43282

Please note: If we request records be submitted from your office, please submit them within the 45 day timeframe noted on the letter received.

Payment integrity audit process timeframe requirements
As part of our ongoing payment integrity audit process, Provider Services informs our providers of any upcoming audit activities requiring medical records that may impact them. Here are our expectations of submission of medical records for audits. There are no exceptions to the following policies, unless otherwise required by law:

Providers have 60 days to submit records. 
We will initiate a Technical Denial recoupment for the claim or the item(s) within the claim that is (are) under review on day 61 for providers who have not submitted all of the requested records by day 60.
Records received from providers after a Technical Denial recoupment has been initiated by Regence will be reviewed in the order received and no later than 30 days after receipt.
Providers may submit records post Technical Denial recoupment within 18 months after payment of the claim or notice that the claim was denied (Note: Hospitals have different time frames. Refer to contract terms for specific timeframe.)
Records received after the timeframes indicated above will not be reviewed. The postmark date, the fax date or email date on the provider's submission will be deemed the date of receipt.
In the event that records are received by Regence after the dates indicated above, Provider Services will notify the provider that the records were late and that no review or adjustment will be made.

Refundable situations
While findings will be different for each audit depending on audit area, contract language and Regence policy, the following are considered refundable to Regence in the absence of specific language in the provider or facility agreement to the contrary. There are no exceptions to this, unless otherwise required by law:

Items not listed within the operative report or documented in the medical record
Items for which there is no physician's order (even if documented in the medical record)
Notification from the provider that he or she has no records for date of service; all charges will be removed

 

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