Claim Audit Information for Providers

Findings and Audit Determination Letters

When the claims audit is complete, HMS will send the provider a letter that explains the findings. If applicable, a list of claims that were incorrectly paid will be included along with the reasons for the determinations.

Providers may dispute the findings if they believe there are appropriate reasons. The letter will include instructions for disputing the audit findings, including a time period for rebuttals established by the health plan.

No Finding Determination

The letter may notify the provider of a “no finding” determination, indicating the review of medical records revealed no improper payments and no further action will be taken. 

Overpayment Letter

An overpayment letter will be part of an audit packet. Along with instructions for next steps there are other important documents, including:

  • Findings summary. This summary lists all claims that were reviewed and shows which were approved and which are identified as an overpayment.
  • Denial letter. For each denied claim, a denial letter will be included providing specific information to understand why it was denied.

Technical Denial

HMS sends a technical denial letter if the requested medical records weren’t received by the deadline or if they were incomplete. When a technical denial is issued, HMS may include a recommendation that the payer recoup payment from the provider for the claims in question.

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