Cotiviti Pre-Payment Claims Pattern Review (CPR)

Background

Cotiviti’s Pre-Payment Claims Pattern Review (CPR) solution will pause claim processing for providers whose billing behaviors require validation before paying. Providers that are selected by Cotiviti will be asked to submit medical records related to claims under review.

The pre-payment audit will be reviewed in 90 days to determine compliance with billing and documentation requirements.

Reasons that providers are placed on Pre-Payment review may be due to:

• Potential outlier billing
• Medically Unlikely Edits
• Excessive Supplies

The provider must demonstrate a minimum accuracy rate of 90% with billing and documentation requirements for the pre-payment audit flags to be removed.

Applicable lines of business: PA Medicare and PA Medicaid

Implementation

This solution went live on June 19, 2023. HRP will deny CPR flagged claims using Message Code WA008.

Record Retrieval

Please send the medical records documentation using one of the following methods:

1. Upload to the Provider Connection Portal:
   1. The Provider Connection Portal is the new way for Providers to submit claim information to Cotiviti quickly, easily, and securely - all online. You will need your portal request code (found on attachment “A” of the medical request form) to upload a document.
2. Securely faxing to 800-317-8098.

Please note, failure to submit medical records within the 28-day timeframe will result in denial of payment.

Appeals

Where to send Appeals for Claims Pattern Review?

Providers have the right to submit for review any claim they feel was denied or paid incorrectly. The Cotiviti CPR Appeals process is changing to streamline the process for providers. Providers will now have three options to send in Cotiviti CPR Appeals:

1. Direct upload to the Secure Portal. Simply click on the “Submit Records” button and enter your password high90CCVC.
2. Secure faxing to 800-409-0499.
3. Mailing the records directly to Cotiviti. Please mark the envelope “Confidential” and send to:

C/O Cotiviti-6150
10701 S Riverfront Pkwy,
Box 12017
South Jordan, Utah 84095

Highmark Wholecare appreciates the service you provide our members and looks forward to a long-standing partnership improving the health of our communities one member at a time.