We're allowing more time for audit appeals, effective Jan. 1, 2025

Effective Jan. 1, 2025, we’ve increased the window of time you have to appeal adverse audit results and technical denials from 30 days to 60 days. This applies to all audit types for all vendors.

We’re in the process of updating the audit findings letters providers receive. Some audit letters may still state 30 days; however, we’ll honor the 60-day window in all cases as will our vendors.

Background: audits & technical denials

When a paid claim is identified for audit and requires medical record review, you’ll receive three written requests to submit medical records. These letters include a list of the requested medical records along with instructions and a deadline for submission.

If you don’t respond with the requested medical records by the deadline, we deny the paid claim to provider liability and take back the paid funds. This is a technical denial.

How to appeal audit results & technical denials

You have the right to appeal both adverse audit results and technical denials. The appeals process varies by audit type (i.e., facility vs DRG) – get more information.