CODA audits
The scope of our Claims Opportunity Detection Audits (CODA) program with vendor Performant Recovery Inc. includes duplicate claims for professional, outpatient and inpatient services.
Please don’t submit a replacement claim once a claim has been selected for a pre- or post-payment review.
Level I audit disputes
As of Mar. 19, 2023, providers have one audit appeal right.
If you receive a CODA change notification letter from Performant Recovery Inc, one of our vendor partners, and you disagree with their findings and wish to appeal, submit an appeal within 30 days from the date of the notification letter.
The appeal request must include evidence to support why you feel the services provided are covered and were properly coded and correctly billed.
Include the following data elements in the appeal:
• Claim number(s)
• Date of this letter
• A summary and relevant evidence for reconsideration
Fax your appeal to 925.245.8243 or mail to:
Performant Recovery, Inc.
Attn: Appeals Dept.
P.O. Box 60410
San Angelo, TX 76906-0410
Technical denials
For each claim requiring medical record review, three request letters are sent. When a provider doesn’t respond to these requests – whether from Priority Health or one of our vendors – by the deadline, we’re unable to substantiate the care provided and will issue a technical denial.
This is a denial of the entire paid claim, after which we'll recoup funds following our standard process for correcting overpayments.
To dispute a technical denial, follow the appeal process for the appropriate audit type.