Cotiviti FAQ Guide Related to Post-Payment Claims Review

Date: December 5, 2025

Attention: All Providers

Call to action: Texas Children’s Health Plan (TCHP) reminds providers of our partnership with Cotiviti, Inc (Cotiviti), which supports program integrity and improves claims processing.

We recently expanded our collaboration with Cotiviti to enhance the appeals process and periodic post-payment reviews of paid medical claims, ensuring alignment with Texas Medicaid requirements and industry-standard guidelines.

Cotiviti’s staff includes registered nurses, medical and claims experts with varying expertise including, but not limited to, coding, claims operations and quality. They work collaboratively with TCHP and your staff in creating effective strategies, plans and activities to prevent both future payment errors and improving the reimbursement process.

Cotiviti is currently conducting audits, and will introduce the following audit programs:

• Diagnosis Related Group – a review process to ensure the code assignment using clinical documentation is valid based on diagnosis, sequencing and coding guidelines.
• Short Stay – a review process to ensure the appropriate patient status is assigned and documented based on the different types of care (ED, observation, inpatient).

Helpful Resources:

• FAQ Guide – View FAQs for answers to common questions about this collaboration.
• Cotiviti Provider Connection Portal – Submit claim information and medical records quickly and securely. If you haven’t registered yet, creating an account is quick and essential for protecting sensitive health information.

How this impacts providers: If selected for an audit, you will receive a letter from Cotiviti requesting medical records for a specific date of service (DOS). Please comply promptly to avoid delays.

If you have any questions or require additional information, please reach out to your assigned Account Lead or Provider Relations Liaison (PRL). If you’re unsure who your Account Lead or PRL is, you can find contact details on our Meet Our Team page.

Thank you for your continued partnership as we work to improve the quality and accuracy of our claims processing.

For access to all provider alerts: www.texaschildrenshealthplan.org/provideralerts.