Welcome, Providers!

As part of our ongoing Payment Integrity Program, a new initiative will begin September 1, 2025. This program involves review of the medical records associated with an identified inpatient claim to ensure that the documentation in the medical record fully supports the diagnosis and procedure codes that were billed.

What to Expect:

• Claims selected for review will be reflected as denied on the Remittance Advice with reason code 602 – Medical record required for DRG validation.
  • CARC - 252 - An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).
  • RARC - M127 - Missing patient medical record for this service.
• You will receive a letter from Cotiviti requesting the medical records related to the denied claim(s).
• The letter will specify the required documentation needed to complete the review and the timeframe for submission.

Lines of Business Impacted:  All

Action Required:

• Please submit the requested medical records within 60 calendar days of receiving the Cotiviti letter.
• Timely submission is essential to ensure a timely and efficient review of the claim.

Additional Information:

• Cotiviti Claim Review FAQ

If you have any questions, please contact your Fidelis Care Provider Relations Specialist. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.