Provider Self-Audits

Federal and state regulations require providers to routinely audit claims for overpayments. To meet this requirement, providers must notify Highmark Wholecare in writing of the reason for the overpayment and return the full amount of the overpayment within 60 days of the date they identified the overpayment.

Providers can submit the Provider Self-Audit form that is located on the Highmark Wholecare website under the Provider Resource Center.

Information to Submit for Self-Identified Overpayment:

When submitting information for an identified overpayment, please include the following:

• Provider information (i.e. Name, NPI, TIN, Contact Information, etc.)
•  Self-audit/overpayment information
•  Period of claims
•  For claims more than two years old, please provide a check.
• For claims less than two years old, retraction of claims is preferred.
• List of affected claims and/or extrapolation calculation used to determine overpayment amount.

TRENDSubmit: Provider Self-Reporting Process

Providers can electronically submit overpayments via TRENDSubmit. This secure, online process allows providers to be notified of claim retractions in real-time and eliminates the lengthy manual paper process. The TRENDSubmit team provides user training resources and ongoing support.

Providers can contact Jennifer Baron (jbaron@trendhealthpartners.com) in order to initiate TRENDSubmit access.

If you have any questions regarding Provider Self-Audits, you can contact Highmark Wholecare’s Special Investigation Unit (SIU) at FIPR-ProviderSelfAudits@highmark.com. Additional information on provider self-audits can be found in the Medicaid and Medicare Provider Manuals.

Trend Health Partners is a separate company that provides post-payment accuracy and integrity solutions.