Incorrect Coding Audits Sample Letter


Provider Appeals Department
City, State, ZIP Code

Re: Post payment refund requests based on incorrect coding audits


Health Plan ID Number: Group Number:
Insured/Plan Member: Patient Name:
Claim Number: Claim Date:

Dear Sir/Madam:

{Insert org name here}, is deeply concerned about {Ins. Co's name} policy of post payment refund requests based on 3rd party incorrect coding audits. While we recognize that audits may serve as a useful tool in determining appropriate submission of claims, we hope to ensure that the reasons and the process are fair to our physicians and patients.

Our members would appreciate a detailed explanation as to why you believe the refund is legitimate, the procedure by which the audit was conducted, and the process of this review. . This may include details of your bundling edits, fee schedules, and provider bulletins. We believe the claim was submitted correctly based on CPT guidelines, was medically necessary, and the patient was eligible at the time of service Enclosed is a copy of the patient's policy which identifies this procedure as covered. Upon request we can produce documentation to support the claim.

As non-participating physicians, our group is not bound by refund limitations. (If you are participating, quote contract language)

It is our practice to not consider refunds beyond 120 days, which is consistent with your limitations for payment for claims submission. 

The state law in ______ (your state if statute exists …see attached appendix) limits this to ___ days.
We look forward to a prompt and thorough resolution to this issue. Please feel free to contact us for any further information you may require.


[Physician Name]


Appendix A

States That Have Established Time Limits on the Detection and Recovery of Overpayments


Alabama (Code of Alabama 27-1-17) Missouri (HB 328 & 88, 2001)
Arizona (Insurance Code 20-462) New Hampshire (Insurance Code 420-J:8-b)
California (Safety Code Sec. 1371) Ohio (Insurance Code 3901.38.8)
Colorado (HB 99-1250, 1999) Oklahoma (HB 1745, 1999)
Florida (State Statutes 627.6131, 2003) Texas (Insurance Code Title 28, 21.2805)
Georgia (Annotated Code 33-29-3) Utah (SB 69, 2001)
Iowa (Admin. Code 191-15.32 (507B)) Virginia (Insurance Code 38-2-3407.15)
Kentucky (SB 279, 2000) Washington (SB 6184, 2004)
Louisiana (HB 2052, 1999) West Virginia (Insurance Code 33-45-2)
Maryland (SB 335, 1997)  

* American Association of Oral Maxillofacial Surgery (OMFS)

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