Fraud, Waste and Abuse Audits and Medical Record Request Standards

The Financial Investigations and Provider Review (FIPR) Team is responsible for conducting audits regarding Fraud, Waste and Abuse (FWA). If selected for an audit, you will receive a letter from the primary investigator, or delegates that have been contracted by the Plan, requesting medical records or the identification of an overpayment. The letter will include specific instructions on how to respond.

If Highmark Wholecare requests medical records, you must provide copies of the records at no cost to the Plan. This includes notifying any third party who may maintain medical records of this stipulation. In addition, you must provide access to any medical, financial, or administrative records related to the services provided to our members within thirty (30) calendar days of our request or sooner. All required documentation must be submitted at the time of the original medical record request. Additional documentation will not be accepted after the review is complete.

Failure to provide requested medical records within the specified timeframe will result in claims being denied.

We require medical records to comply with CMS, AMA, NCCI, NCQA, HIPAA Transactions and Code Sets, Medicaid regulations, and Medicare manuals as well as other applicable professional associations and advisory agencies. For more information on medical record requests and standards, please refer to the Medicaid and Medicare Provider Manuals, located on the Provider Resource Center under “Resource Center”.