Provider Self-Audits for Overpayments

Federal and state regulations require providers to routinely audit claims for overpayments. A process is in place for providers to report the receipt of an overpayment. Providers must notify HHO WV in writing of the reason for the overpayment as well as returning the full amount of the overpayment within 60 days after the date on which they identified the overpayment.

Providers can submit the Provider Self-Audit form that is located on the HHO WV website under Provider Forms and Reference Material.

For more information on self-audits, reference the following resources:

• CMS e-bulletin on Self-Audits
• WV Bureau for Medical Services (BMS) Office of Program Integrity (OPI) website
• Office of Inspector General (OIG) Health Care Fraud Self-Disclosure Protocol
• Self Audits Overpayment Form (PDF)

If you have any questions regarding Provider Self-Audits, email ProviderSelfAudits@highmark.com.

Information to Submit for Self-Identified Overpayment:

When submitting information for an identified overpayment, please include the following:

• Provider information (i.e. Name, NPI, TIN, Contact Information, etc.) 
• Self-audit/overpayment information      
• Period of claims
  • For claims more than two years old, please provide a check.
  • For claims less than two years old, retraction of claims is preferred.
• List of affected claims and/or extrapolation calculation used to determine overpayment amount.
• Other information (as required)

Please be aware if a listing of claims is not provided, HHO WV cannot guarantee that the claims will not be audited again, for the same reason. Deposit of a provider check or retraction of the requested claims does not constitute complete agreement to the submitted self-audit results or overpayment amount. The Financial Investigations and Provider Review (FIPR) Department may contact the provider to discuss self-audit results as necessary. 

TRENDSubmit: Provider Self-Reporting Process

Providers can electronically submit overpayments via TRENDSubmit. This secure, online process allows providers to be notified of claim retractions in real-time and eliminates the lengthy manual paper process. The TRENDSubmit team provides user training resources and ongoing support.

Please see below for more information on TRENDSubmit. In addition, providers email Lauren Smith to initiate TRENDSubmit access.

• TRENDSubmit Flyer