New DRG Claim Review Initiative – Effective September 1, 2025
2025/8/1
•
Posted by Provider Relations
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.
- 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:
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.