3.2.2 Services: A. Home Health Audit and Review. • Vendor to define criteria and scope for pre-payment and post-payment review. • Audit services apply to both HCFA1500 (professional charges) and UB04 (facility charges). • Vendor sets scope for coordinating home health claim reviews with CareOregon. • Post-pay review may include claims up to 12 months post-processing. • SNF and home health claims compliance audits, including delivery of audit reports, and any assumptions related to the anticipated schedule. Audit to Include • Billing for services/items not rendered. • Medically unnecessary services. • Duplicate billing. • Incentives to actual/potential referral sources. • Services billed for non-homebound patients. • Recommendations for payments and denials. Review of visit notes and other clinical documentation. Over-/under-utilization. • Insufficient documentation to support reimbursement. • Improper patient solicitation. • Poor subcontractor management causing billing errors. • Orders, Plan of CareOregon, and primary prescriptions alignment. Automation & Analytics Requirements • Vendor automation must not disrupt CareOregon claims examiners’ workflows. • Analytics must support claims examiners' daily operations. • Overpayment analytics must include edit recommendations to avoid repeated errors. Home Health Audit Responsibilities • Vendor verifies medical records support claim validity. • Review revenue codes, Current Procedural Terminology (“CPT”), Healthcare Common Procedure Coding System (“HCPCS”), International Classification of Diseases (“ICD”). • Request and evaluate provider medical records.
