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Network Health

Audit program

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Network Health conducts internal and external claims audits to validate accuracy of payment and confirm that claims accurately represent the services provided to Network Health members.

Internal audits:

  • Network Health conducts bi-monthly random audits of finalized claims to determine payment and financial accuracy.
  • Network Health conducts issue-specific audits (e.g., duplicate payment, high dollar claims) on a weekly basis.
  • Network Health conducts ad hoc audits for targeted issues.

External audits:

  • Network Health contracts with an outside vendor to perform on-site audits of claims that meet our benchmarking standards.
  • The external auditor will notify the provider in question 30 days prior to the on-site review to schedule an appointment for the on-site audit.

Appeals:

  • Network Health’s Provider Manual specifies denial appeals information, including timeframes and resolution time.
  • The appeal reviewer includes identifying information in the appeal file.

Review rationale:

  • Network Health bases its denial decisions on regulations from Centers for Medicare and Medicaid Services (CMS), National Correct Coding Initiative (CCI), and Medicaid.
  • You can find regulation information in the Ingenix Manuals for CPT, HCPCS, and ICD-9 codes.

 
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