Onsite Audits. Provider shall permit Government Officials and Blue Shield to conduct periodic onsite audits of their records. Blue Shield shall provide Provider five (5) business days’ advance notice (or fewer if mutually agreed upon by the parties) of any proposed onsite audit by Blue Shield. Audits will be performed on-site or otherwise and may involve statistically valid sampling techniques of Provider that are deemed necessary to include, but not limited to, medical practice audits, medical necessity reviews, data validation reviews, billing and claims payment audits, coding audits and quality improvement audits. Further, provider agrees to participate in any corrective action plan required by Blue Shield. Based on such review, Blue Shield may deny payment, reject claims, and/or review claims on a retrospective basis and recover any overpayments, consistent with the requirements set forth in Section 1300.71(b)(5) of Title 28 of the California Code of Regulations. Provider may not bill for services rendered by a practitioner if such services are subject to billing independently by practitioner, another provider, and/or another entity subject to another agreement or arrangement with Blue Shield.
Onsite Audits. Provider shall permit Government Officials and Health Plan to conduct periodic onsite audits of their records. Health Plan shall provide Provider five (5) business days’ advance notice (or fewer if mutually agreed upon by the parties) of any proposed onsite audit by Health Plan. Audits will be performed on-site or otherwise and may involve statistically valid sampling techniques of Provider that are deemed necessary to include, but not limited to, medical practice audits, medical necessity reviews, data validation reviews, billing and claims payment audits, coding audits and quality improvement audits. Further, provider agrees to participate in any corrective action plan required by Health Plan. Based on such review, Health Plan may deny payment, reject claims, and/or review claims on a retrospective basis and recover any overpayments, consistent with the requirements set forth in Section 1300.71(b)(5) of Title 28 of the California Code of Regulations. Provider may not bill for services rendered by a practitioner if such services are subject to billing independently by practitioner, another provider, and/or another entity subject to another agreement or arrangement with Health Plan.
Onsite Audits. Provider shall permit Government Officials and Blue Shield to conduct periodic onsite audits of their records. Blue Shield shall provide Provider five (5) business days’ advance notice (or fewer if mutually agreed upon by the parties) of any proposed onsite audit by Blue Shield. Audits will be performed on-site or otherwise and may involve statistically valid sampling techniques of Provider that are deemed necessary to include, but not limited to, medical practice audits, medical necessity reviews, data validation reviews, billing and claims payment audits, coding audits and quality improvement audits. Further, provider agrees to participate in any corrective action plan required by Blue Shield. Based on such review, Blue Shield may deny payment, reject claims, and/or review claims on a retrospective basis and recover any overpayments. Provider may not bill for services rendered by a practitioner if such services are subject to billing independently by practitioner, another provider, and/or another entity subject to another agreement or arrangement with Blue Shield.
