Common use of AUDIT AND RECOVERY Clause in Contracts

AUDIT AND RECOVERY. 4.1 BCBSM or its designee shall have access to review, photocopy and audit Member's medical records and other pertinent appointment, billing and financial records of TRUST PRACTITIONER to verify medical necessity, appropriateness of payment and for fraud/abuse investigations. Quality and utilization reviews conducted under other BCBSM programs may be considered when evaluating TRUST PRACTITIONER's performance under this TRUST Network. 4.2 BCBSM may conduct onsite audits during TRUST PRACTITIONER’s regular business hours. BCBSM’s inspection, audit and duplication of records shall be allowed during regular business hours, upon reasonable notice of dates and times. 4.3 BCBSM shall have the right to recover amounts paid TRUST PRACTITIONER for services not meeting the applicable benefit or medical necessity criteria established by BCBSM, overpayments, services not documented in TRUST PRACTITIONER’s records, any services not received by Member, non-Covered Services or for services furnished when TRUST PRACTITIONER’s license was lapsed, restricted, revoked or suspended. BCBSM shall have the right to initiate recovery of amounts paid for services up to eighteen (18) months from the date of payment or up to twenty-four (24) months from the date of payment as required by a (a) self-insured plan or (b) state or federal government plan. In instances of fraud, there will be no time limit on recoveries. BCBSM will not utilize statistical sampling methodologies to extrapolate refund requests on medical necessity issues identified through sampling. BCBSM may extrapolate refund recoveries from statistically valid samples involving issues other than medical necessity. 4.4 TRUST PRACTITIONER shall promptly report overpayments to BCBSM discovered by TRUST PRACTITIONER, and agrees BCBSM will be permitted to deduct overpayments (whether discovered by TRUST PRACTITIONER or BCBSM) from future BCBSM payments, along with an explanation of the recovery taken. In audit refund recovery situations, where TRUST PRACTITIONER appeals the BCBSM determination, BCBSM will defer deduction of overpayments until the arbitration determination, or the last unappealed determination, whichever occurs first. Audit refund recoveries and other overpayment obligations which cannot be fully repaid over the course of one month, will bear interest at the BCBSM prevailing rate, until fully repaid. Interest will run from the date of arbitration determination or last date an appeal could have been filed whichever is earlier. TRUST PRACTITIONER agrees that filing an appeal tolls the applicable statute of limitations that may apply to BCBSM actions relating to the overpayment or recovery. 4.5 Notwithstanding any other provision of this Agreement, TRUST PRACTITIONER shall not xxxx, charge, collect or attempt to collect payment from a Member for a service for which payment has been denied by BCBSM or for which recovery of payment has been sought as determined in Section 4.3. 4.6 TRUST PRACTITIONER shall not xxxx BCBSM for Covered Services rendered to themselves or immediate family members (mother, father, sister, brother, spouse or child).

AUDIT AND RECOVERY. 4.1 If and/or when applicable, TRUST PRACTITIONER shall sign and date all medical records related to the provision of Covered Services to MIChild Members under this Agreement, and shall retain such records for seven (7) years, or as otherwise required by law. Medical records include but are not limited to, records relating to outpatient and emergency care, specialist referrals, ancillary care, diagnostic test findings including laboratory and radiology, prescriptions for medications, inpatient discharge summaries, histories and physicals, immunization records, other documentation sufficient to fully disclose the quantity, quality, appropriateness, and timeliness of services provided. BCBSM or its designee shall have access to review, photocopy and audit Member's medical records and other pertinent appointment, billing and financial records of TRUST PRACTITIONER to verify medical necessity, appropriateness of payment and for fraud/abuse investigations. Quality and utilization reviews conducted under other BCBSM programs may be considered when evaluating TRUST PRACTITIONER's performance under this TRUST Network. 4.2 BCBSM may conduct onsite audits during TRUST PRACTITIONER’s regular business hours. BCBSM’s inspection, audit and duplication of records shall be allowed during regular business hours, upon reasonable notice of dates and times. 4.3 BCBSM shall have the right to recover amounts paid TRUST PRACTITIONER for services not meeting the applicable benefit or medical necessity criteria established by BCBSM, overpayments, services not documented in TRUST PRACTITIONER’s records, any services not received by Member, non-Covered Services or for services furnished when TRUST PRACTITIONER’s license was lapsed, restricted, revoked or suspended. BCBSM shall have the right to initiate recovery of amounts paid for services up to eighteen (18) months from the date of payment or up to twenty-four (24) months from the date of payment as required by a (a) self-insured plan or (b) state or federal government plan. In instances of fraud, there will be no time limit on recoveries. BCBSM will not utilize statistical sampling methodologies to extrapolate refund requests on medical necessity issues identified through sampling. BCBSM may extrapolate refund recoveries from statistically valid samples involving issues other than medical necessity. 4.4 TRUST PRACTITIONER shall promptly report overpayments to BCBSM discovered by TRUST PRACTITIONER, and agrees BCBSM will be permitted to deduct overpayments (whether discovered by TRUST PRACTITIONER or BCBSM) from future BCBSM payments, along with an explanation of the recovery taken. In audit refund recovery situations, where TRUST PRACTITIONER appeals the BCBSM determination, BCBSM will defer deduction of overpayments until the arbitration determination, or the last unappealed determination, whichever occurs first. Audit refund recoveries and other overpayment obligations which cannot be fully repaid over the course of one month, will bear interest at the BCBSM prevailing rate, until fully repaid. Interest will run from the date of arbitration determination or last date an appeal could have been filed whichever is earlier. TRUST PRACTITIONER agrees that filing an appeal tolls the applicable statute of limitations that may apply to BCBSM actions relating to the overpayment or recovery. 4.5 Notwithstanding any other provision of this Agreement, TRUST PRACTITIONER shall not xxxx, charge, collect or attempt to collect payment from a Member for a service for which payment has been denied by BCBSM or for which recovery of payment has been sought as determined in Section 4.3. 4.6 TRUST PRACTITIONER shall not xxxx BCBSM for Covered Services rendered to themselves or immediate family members (mother, father, sister, brother, spouse or child).

AUDIT AND RECOVERY. 4.1 If and/or when applicable, TRUST PRACTITIONER shall sign and date all medical records related to the provision of Covered Services to MIChild Members under this Agreement, and shall retain such records for seven (7) years, or as otherwise required by law. Medical records include but are not limited to, records relating to outpatient and emergency care, specialist referrals, ancillary care, diagnostic test findings including laboratory and radiology, prescriptions for medications, inpatient discharge summaries, histories and physicals, immunization records, other documentation sufficient to fully disclose the quantity, quality, appropriateness, and timeliness of services provided. BCBSM or its designee shall have access to review, photocopy and audit Member's medical records and other pertinent appointment, billing and financial records of TRUST PRACTITIONER to verify medical necessity, appropriateness of payment and for fraud/abuse investigations. Quality and utilization reviews conducted under other BCBSM programs may be considered when evaluating TRUST PRACTITIONER's performance under this TRUST Network. 4.2 BCBSM may conduct onsite audits during TRUST PRACTITIONER’s regular business hours. BCBSM’s inspection, audit and duplication of records shall be allowed during regular business hours, upon reasonable notice of dates and times. 4.3 BCBSM shall have the right to recover amounts paid TRUST PRACTITIONER for services not meeting the applicable benefit or medical necessity criteria established by BCBSM, overpayments, services not documented in TRUST PRACTITIONER’s records, any services not received by Member, non-Covered Services or for services furnished when TRUST PRACTITIONER’s license was lapsed, restricted, revoked or suspended. BCBSM shall have the right to initiate recovery of amounts paid for services up to eighteen (18) months from the date of payment or up to twenty-four (24) months from the date of payment as required by a (a) self-insured plan or (b) state or federal government plan. In instances of fraud, there will be no time limit on recoveries. BCBSM will not utilize statistical sampling methodologies to extrapolate refund requests on medical necessity issues identified through sampling. BCBSM may extrapolate refund recoveries from statistically valid samples involving issues other than medical necessity. 4.4 TRUST PRACTITIONER shall promptly report overpayments to BCBSM discovered by TRUST PRACTITIONER, and agrees BCBSM will be permitted to deduct overpayments (whether discovered by TRUST PRACTITIONER or BCBSM) from future BCBSM payments, along with an explanation of the recovery taken. In audit refund recovery situations, where TRUST PRACTITIONER appeals the BCBSM determination, BCBSM will defer deduction of overpayments until the arbitration determination, or the last unappealed determination, whichever occurs first. Audit refund recoveries and other overpayment obligations which cannot be fully repaid over the course of one month, will bear interest at the BCBSM prevailing rate, until fully repaid. Interest will run from the date of arbitration determination or last date an appeal could have been filed whichever is earlier. TRUST PRACTITIONER agrees that filing an appeal tolls the applicable statute of limitations that may apply to BCBSM actions relating to the overpayment or recovery. 4.5 Notwithstanding any other provision of this Agreement, TRUST PRACTITIONER shall not xxxxbill, charge, collect or attempt to collect payment from a Member for a service for which payment has been denied by BCBSM or for which recovery of payment has been sought as determined in Section 4.3. 4.6 TRUST PRACTITIONER shall not xxxx bill BCBSM for Covered Services rendered to themselves or immediate family members (mother, father, sister, brother, spouse or child).