Date: June 24, 2024
Attention: All Providers
Effective Date: October 1, 2024
Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that beginning October 1, 2024, we will partner with Cotiviti, Inc (Cotiviti) for periodic post payment reviews of paid medical claims. The post payment reviews to be conducted are: Retrospective Clinical Claim Validation (RCCV) DRG, observation, and readmission reviews. These are the same/similar reviews that are currently being conducted, just with a new vendor, Cotiviti.
What providers can expect:
- CCV reviews are conducted to ensure proper billing. These require a copy of the medical records, which may be requested, if TCHP has not already received the medical records.
- If a claim is identified for either review, you will receive a letter identifying the claim(s) selected and provide detailed information related to guidelines and timeframes to follow.
Cotiviti’s staff includes registered nurses, medical and claims experts with varying expertise including, but not limited to, coding, claims operations and quality. They will work collaboratively with TCHP and you/your staff in creating effective strategies, plans and activities to prevent both future payment errors and improving the reimbursement process. You may already be familiar with Cotiviti as a leader in the industry with health plans across the United States.
Cotiviti’s a Business Associate of TCHP as defined in 45 CFR, § 160.103 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and will perform its responsibilities on behalf of TCHP in full compliance with HIPAA requirements.
Next step for providers: Providers should share this update with their staff. Consistent with this business relationship, we request your assistance in providing Cotiviti’s staff access to medical and/or financial information necessary to complete these reviews to the same extent TCHP’s staff would be authorized to access such records.
If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.
For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.
