Vendor Audit Letter Template (Page 2 of 6) in pdf

iv.

Provider Name

Provider status (par vs. non par)

vi.

Tax Identification Number/NPI

vii.

Procedure code/Revenue Codes

viii.

Diagnosis Codes

ix.

Amount Paid

Denial code

xi.

Type of claim (clean vs. unclean)

c. A fee schedule of the claims paid included in the sample

d. Copies of the Explanation of Payment and cashed checks

e. A list of denial codes and explanation codes presented on the EOB or

Remit.

f. All benefit grids in effect during the period in question

g. Authorization screen print for each claim selected

h. Line level payments – Billed Amount, Allowed Amount, Net/Paid

Amount

2. All Department of Insurance (DOI) inquiries (claims payment, quality of care,

treatment from office staff or provider etc) involving an (Name) member or

services provided to an (Name) member. From the total, (Name) shall select a

sample and request the following:

a. A copy of the actual inquiry from the DOI

b. A copy of the response to the DOI

3. A copy of your claims Policies and Procedures, including the claims

reconciliation procedures

When sending over the claim samples, please create three (3) binders-

Medical, Hospital and DOI, and include, for each claim being audited, the items

requested above. Items c, e, & f need not be duplicated for each claim if the information

is the same for all. We will review the claims onsite at (Name), and will then incorporate

the feedback in the overall Audit Findings document.

CREDENTIALING

(Name) shall randomly select a sample of 5% or 50 files, whichever is less; at a minimum

there will be at least 20 provider files selected (10 credentialing and 10 re-credentialing)

from a provider listing from your last cycle. Please email the listing and mail copies of

the selected files to my attention.

1. Credentialing and recredentialing policies and procedures (should include process

for verification of participating provider credentials)

2. Confidentiality Policy

3. Copies of the credentialing committee minutes for providers selected for audit

Vendor Audit Letter Template Page 2