Payment Integrity

Page last updated on: 6/20/25

We’re committed to ensuring the effective use and management of resources in care delivery to our members. To achieve this aim, we operate a Payment Integrity program. Our program focus on billing / coding errors and overutilization of services or other practices that directly or indirectly result in unnecessary costs.

Our Payment Integrity team uses both internal and external resources, including third-party vendors, to help ensure claims are paid accurately and according to our provider contracts. In the absence of a policy, we may adopt Centers for Medicare and Medicaid Services (CMS) guidelines.

Payment Integrity code edit relationships and edits are based on federal Centers for Medicare and Medicaid Services (CMS) guidelines, AMA and published specialty specific coding rules. Code Edit Rules are based on information received from the National Physician Fee Schedule Relative File (NPFS), the Medically Unlikely Edit table (MUE), the National Correct Coding Initiative (NCCI) files, Local Coverage Determination/National Coverage Determination (LCD/NCD) and State-specific policy manuals and guidelines as specified by a defined set of indicators in the Medicare Physician Fee Schedule Data Base (MPFSDB).

Our clinical edits evaluate billed codes in relationship to each other to identify unbundled procedures, surgical coding errors, invalid data relationships, patterns of utilization that deviate from practice standards and diagnoses or procedures that may be invalid for the age and/or gender of the patient. Ultimately, clinical edits ensure that claims are:

  • Billed appropriately based on clinical documentation and national coding standards
  • Results of erroneous coding detections are used in paying the claim correctly
  • A correctly paid claim is expected to be reported to government agencies
  • Certain high-dollar claims are reviewed more extensively using treatment documentation to validate what was coded

Learn more about clinical edits

Our Special Investigations Unit (SIU) and Payment Integrity (PI) teams administer audits with the help of our vendor partners, to make sure already processed claims were billed and handled properly.

Documentation and coding errors may not be intentional but can have significant impact on the member and health plan. It’s important to identify and make corrections when errors are found. We may request medical records or itemized bills to validate the accuracy of a submitted claim. The records and/or documentation substantiate the setting or level of service provided to the patient or validate the procedures, diagnosis or diagnosis-related group (“DRG”) billed by the provider. Other medical record reviews include, but are not limited to, place of service validation, re-admission review, ancillary service reviews, as trends develop.

We use industry standard billing and processing criteria when conducting audits to be sure we’re protecting our customers and meeting compliance and regulatory requirements.

Audits may be:

  • Over the phone
  • On-site visits
  • Internal claims review
  • Client-directed / regulatory investigation
  • Compliance reviews
  • Vendor-assisted

As a Priority Health provider, we ask that you give our Representative/Designee access to examine, audit, scan and copy any/all records necessary during normal business hours. Timely access to the necessary records will result in prompt compliance determination and billing accuracy.

Identifying providers for audit

We follow up on tips and referrals and perform claims data mining to identify suspicious claims that require further investigation. Suspicious claims are audited for validation.

Notifying providers of audits

Providers selected for audit are notified directly by the Priority Health Special Investigations Unit, Payment Integrity or by one of our vendor partners. Our vendor partners identify themselves and indicate they are performing the audit on behalf of Priority Health.

Disputing audit findings

If you’ve been audited and disagree with some or all the audit findings, you may dispute the findings.

Learn more about disputing audit findings

We review claims that may have been related to an accident or worker’s compensation to determine the primary payer for the claim. This helps us ensure we’re only paying for our member’s claims.