Vendor Audit Letter Template (Page 4 of 6) in pdf

1. Quality Management Plan – Program Description

2. Minutes from your Quality Management Committee ((Name) specific or generic)

3. Updated Policies and Procedures for Complaints, Grievances, and Appeals along

with letter templates for all lines of business

4. All Medicare member files for appeals and grievances, including member letters,

documentation of the complaint, Acknowledgement letter, Resolution letter and

whether it’s an appeal or grievance

5. Documentation to support time frames for standard and expedited appeals

6. Reports with respect to Complaints, Grievances and Appeals Activity for all lines

of business including:

a. Performance Improvement Actions

7. Member Satisfaction Surveys and analysis

8. Any Clinical surveys pertinent to Medicaid, Family Health Plus and Child Health

Plus population

UTILIZATION MANAGEMENT

The following information is needed for the Utilization Management Audit:

1. UM Policy and Procedure by product

2. Revised, signed and committee approved UM Program Description

3. Revised, signed and committee approved UM Program Evaluation including UM

Subcommittee

5. Revised, signed and committee approved UM Work Plan (guiding document)

6 Utilization Metrics (Analysis of data)

7. A copy of the statement for compliance regarding confidentiality

8. Any complaints as outlined in the Quality Management section

9. Reports used to identify those members that may require Case Management

Random cases will be reviewed to determine appropriateness of care plan

development

Additionally, please submit a complete list of clinical and administrative determinations

for the following Service Authorization Requests (SARs). Please be sure the list indicates

the product line for each member:

1. Prospective

2. Concurrent

3. Retrospective

(Name) will audit a random number of SAR’s to determine the vendor’s adherence to

mandated timeframes for processing these requests. For any Medicare denials included in

our random sample, we will contact you to obtain the corresponding member files so we

may monitor the criteria used as well as any member correspondences.

COMPLIANCE

The following information is needed for the Compliance Audit:

Vendor Audit Letter Template Page 4