5.2.1.1 Perform targeted claims audits which may be benefit-specific or may be comprehensive of a provider’s complete practice. The scope of these audits will vary; some may include a full review of the claim and provider’s records (on-site or through chart review) to assure that payment received by the provider was warranted as per the PEIA PPB Plan guidelines. 5.2.1.2 Perform targeted eligibility audits which will review PEIA membership for specific eligibility criteria to determine compliance. 5.2.1.3 Assist PEIA in determining the audit topics. PEIA will provide audit specifications at the beginning of each project. 5.2.1.4 Provide a written project plan at the beginning of each audit that outlines the resources and time frames for each audit during the contract period. The project plan shall serve as a snapshot of everything the Vendor is identifying at the time. As new issues arise the project plan shall be updated through mutual consent of PEIA and the vendor. 5.2.1.5 Provide user-friendly status reports with recommendations for improving processes and clearly defined amounts to be recovered. 5.2.1.6 Review and respond (or provide recommendations) to appeals related to audits. 5.2.1.7 Provide advisory services related to the completed audits. 5.2.1.8 If requested by the PEIA, the Vendor’s Project Manager for the PEIA contract shall attend any member or provider group meeting(s), PEIA Finance Board or legislative sessions where the Auditing Services project is the focus. 5.2.1.9 Provide access to all pertinent books, documents, papers and records related to the contract.
