Home Health and Skilled Nursing Facility Audit and Review Services

The vendor is required to provide home health and skilled nursing facility audit and review services for include:
- 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). 
•    Coordinating home health claim reviews with agency. 
•    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.
1. Audit to include
•    Billing for services and items not rendered.
•    Medically unnecessary services.
•    Duplicate billing.
•    Incentives to actual and potential referral sources.
•    Services billed for non-homebound patients.
•    Recommendations for payments and denials. 
•    Review of visit notes and other clinical documentation. 
•    Over- and under-utilization.
•    Insufficient documentation to support reimbursement.
•    Improper patient solicitation.
•    Poor subcontractor management causing billing errors.
•    Orders, plan of agency, and primary prescriptions alignment.
2. Automation and analytics requirements
•    Vendor automation must not disrupt agency claims examiners’ workflows.
•    Analytics must support claims examiners' daily operations.
•    Overpayment analytics must include edit recommendations to avoid repeated errors.
3. 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.
•    Ensure federal, state, and payer guidelines are met.
•    Return audit recommendations to agency in a timely manner, within five days for prepayment claims and thirty days for post-payment claims.
4. Focus areas in claims review
•    Physical, occupational, and speech therapy.
•    Face-to-face documentation.
•    Telehealth services.
•    Physician’s orders and plan of care.
•    General compliance documentation.
•    Visit note documentation.
•    Finding logic to group the PDPMs for complexity of the member.
•    Designating complexity that the facilities are receiving.
5. Communication and adjustments
•    Timely updates and prompt responses to agency inquiries.
•    Adjustments for overpayments must be communicated within the timelines outlined in the deliverables, i.e., five (5) calendar days for pre-payment review and thirty (30) calendar days for post-payment review.
6. Cost containment focus
•    Proposer to provide long-term solutions for cost containment.
- Skilled nursing and hospice facility audit review
•    Define criteria and actions for both pre-payment and post-payment claim reviews.
o    Skilled nursing facility claims.
o    Hospice claims.
o    Both hcfa1500 (professional) and ub04 (facility) forms.
•    Post-payment reviews to look back up to 12 months from processing date.
•    Targeted skilled nursing facility (SNF) reviews to validate:
o    Coding accuracy.
o    Compliance with CMS, state, and health plan policies.
o    Service utilization standards.
1. Medical record review
•    Assess whether records support acuity of care billed.
•    Review shall cover:
o    Revenue codes.
o    Current procedural terminology (CPT) codes.
o    healthcare common procedure coding system (HCPCS) codes.
o    International classification of diseases (ICD) codes.
•    Ensure alignment with federal, state, and payer compliance guidelines
2. Health insurance prospective payment system (HIPPS) code validation
•    Focus on documentation supporting:
o    Physical therapy (“PT”).
o    Occupational therapy (“OT”).
o    Speech-language pathology
o    Nursing services with functional scores.
o    Non-therapy ancillary services.
3. Documentation focus areas
•    Diagnosis coding accuracy.
•    Minimum data set (“MDS”) documentation.
•    Compliance standards.
•    Individual therapy minutes tracked and verified.
4. Automation and analytics requirements
•    Automation must not interfere with agency examiners’ workflows.
•    Analytics must support agency examiners’ work and improve daily progress tracking.

- Contract Period/Term: 3 years
- Questions/Inquires Deadline: November 11, 2025