Coding Corner: Understanding External Cause Codes

As part of Highmark Wholecare’s annual audit process, the Financial Investigations and Provider Review (FIPR) team will request that a selected provider complete the Provider Compliance Assessment and provide supplemental documentation as evidence of the existence and operation of a provider’s compliance program.

The Provider Compliance Assessment is based on the eight elements of an Effective Compliance Program as published under the United States Federal Sentencing Guidelines and is used to assess and document the current state of compliance oversight, management, and risks in a given compliance area.

The process to complete the Compliance Assessment, if selected, is outlined below:

1. Provider Compliance Assessment and Attestation are issued to the provider for review and completion. Providers are allotted 30 days to review and complete this request.
2. Supplemental documentation must be submitted with the completed Assessment as evidence of the existence of policies, training, screenings, etc. as outlined on the Provider Question tab of the Assessment spreadsheet.
3. Once the Assessment is submitted with supplemental documentation, an investigator will review the Assessment and documentation for completion and follow up with any subsequent requests for additional information.

Important Notes:

• The form should be completed by office personnel that have been designated as having compliance oversight and responsibility for the day-to-day operations of the provider’s compliance program.
• Review and complete the Provider Questions tab of the spreadsheet. Questions should be completed and provide specific citations to the supplemental documentation that is being provided to support the specific compliance function or task that is being requested.
• Review and provide attestation on the Attestation tab of the spreadsheet. This document should be signed by the individual who is responding to the request for information on behalf of the provider.
• Supplemental documentation can include, but is not limited to, policies and procedures, evidence of Compliance Training, evidence of delegation oversight, and evidence that Sanction and Exclusion screenings have been conducted

For further information on the Fraud, Waste, and Abuse audit process, please refer to Highmark Wholecare’s Medicaid and Medicare Provider Manuals.