Claim Audit Information for Providers

What to Expect During a Claims Audit

Claim audits are an important tool health plans use to control cost – with help from HMS. Plans are required to manage risk, remain in compliance with government regulations and meet their own fiduciary requirements.

Some types of claim audits include a request for related medical records – but not all (see Audit Types). HMS requests medical records when a claim seems likely to include improper payments, determined through analysis conducted using our proprietary algorithms against our comprehensive data set.

After claims are identified for review, HMS will request relevant documentation from the provider. The provider may receive a Medical Record Request letter, including additional information on the audit being performed and instructions for submitting medical documentation to HMS.

After they are received, members of the HMS clinical review team will perform an in-depth review of the medical records. An audit packet will be mailed to the provider, informing them of the results.

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