Claims Audit Services

The Vendor is required to provide to conduct medical claim audit services, prescription drug claim audit services, pharmacy rebate audit services, and clinical validation review services.
- Services:
• Medical Claim Audit Services
• Prescription Drug Claim Audit Services and Pharmacy Rebate Audit Services
• Clinical Validation Review Services
• Optional and/or Supplemental Services
- Determine whether claims payments are accurate, allowable, adjudicated, and paid in accordance with contractual arrangements. This includes out-of-network and emergency claims.
- Auditing, identify any claims processing problems or areas, including but not limited to, coordination of benefits (“COB”), detection of fraudulent claims, duplicate claims, overcharging by providers, and unnecessary services in need of further review or audit.