Payment integrity

Medical Record Requests

We will request medical records if we are conducting a Clinical and Coding Validation (CCV) Audit. If there are not already suitable medical records on file, you will receive a documentation request letter from our internal Payment Integrity (PI) team or through our trusted vendors.

• For Prepay CCV Audits, you will receive one medical record request letter.
• For Postpay CCV Audits, you may receive up to three medical record request letters.

This page will cover how to respond to medical records requests and provide details on how results will be communicated.

Timeframes for responding to medical record requests

• For Prepay CCV Audits: Records must be received within 30 days of the date on the medical request letter or according to your contract guidelines.
• For Postpay CCV Audits: Records must be received within 30 days of the date on the medical request letter (you will have three chances to submit records) or according to your contract guidelines.

How to respond to medical record requests from Devoted

You can submit medical records requested by Devoted through several methods:

Via Fax

Securely send your documents to Devoted Health at: (866) 312-3986

Via Mail

Devoted Health Payment Integrity Department

PO BOX 211524

Eagan, MN 55121

Please mark the envelope as “Confidential" and send via USPS to ensure delivery. Some mail carriers don’t deliver to PO boxes.

Via the Devoted Provider Portal

Please note that this method is available for contracted providers.

1. Login to the Devoted provider portal via the Devoted Health Payer Space in Availity. For more information about using our provider portal, see our website here.
2. Once on the portal homepage, navigate to “Claims Requiring Additional Documentation” for the full list of adjudications we’ve requested medical records for. If the audit is being conducted by a vendor, the adjudications for which vendors have requested medical records will NOT be shown on the provider portal.
3. Select “Attach medical documentation” on the right for each adjudication that requires medical records. Note: providers should ONLY submit the medical records requested for the claim audit associated with the adjudication. Records should contain at least a couple of identifying demographics (e.g., DOB, member name).
4. Click “Ok”. You will be able to see the name of the submitted file to confirm the upload was successful. The button to upload medical records for that adjudication will remain visible for approximately one hour. After that, the button will disappear if the upload was successful.

How to respond to medical record requests from our vendors

If the audit is being conducted by one of our vendors, please follow the specific instructions provided in their request letter. Instructions are summarized below for quick reference:

Cohere

• Provider portal: Cohere Validate
• Fax: (570) 682-7658
• Mail (mark envelope "Confidential")
  Cohere Health Payment Integrity Department
  PO Box 1290
  Portsmouth, NH 03802
• Contact Cohere Health at (888) 348-8667, Monday - Friday from 8:00am to 5:00pm local time

Cotiviti

• Provider portal: Cotiviti Provider Connection
• Fax: (888) 829-3414

EXL

• Provider portal: EXL Health - Provider Portal
• Electronic submission (SFTP): See SFTP instructions
• Mail: See mail instructions

Optum

For prepay medical records requests, an initial request is sent followed by a reminder when there are 15 days left for record submission.

For FCRI / Facility Audits - for questions, please call: (833) 833-2093

• CIOX e-portal
• Fax: (949) 315-7942
• Secure online file drop: facilitydrop.com
• USPS mail:
  Attn: Optum Health
  c/o Devoted Health Plan
  16350 Bake Pkwy.
  Irvine, CA 92618

For FCR Professional Audits

• Website: Optum Provider Document Portal
• Fax: (844) 226-3364

Penstock

• Provider portal: Hubshare (first-time users should email Devoted_service_desk@penstockgroup.com for account setup)
• Regular mail:
  Penstock Group, LLC
  Attn: Devoted Document Imaging Center
  PO Box 1370
  Williamsville, NY 14231
• Overnight delivery (FEDEX, UPS, etc.):
  Penstock Group, LLC
  Attn: Devoted Document Imaging Center
  5325 Sheridan Drive, Suite 1370
  Williamsville, NY 14221
  Fax: (860) 435-7020

Results of medical record submission to a vendor

If there are findings for a prepay or postpay audit performed by a vendor, you will receive a findings letter from them.

Coordination of Benefits for Motor Vehicle Accidents

In accordance with Centers for Medicare & Medicaid Services (CMS) Medicare Secondary Payer (MSP) requirements and applicable Coordination of Benefits (COB) rules, Devoted may deny claims when our records indicate the services are related to a Motor Vehicle Accident (MVA) and another insurer may be primary for payment of the service. To help us resolve these claims quickly and ensure the correct party is billed, please review the requirements below for submitting proof of benefit exhaustion or documentation demonstrating the services were unrelated to a MVA.

Acceptable documents types

Providers may submit the following types of documentation:

If benefits have been exhausted:

• Auto Carrier Explanation of Payment (EOP): An EOP from the auto carrier showing the claim was processed and either paid or denied, including applicable line-item denial reasons, remark codes, or indicators showing benefits have been exhausted.
• Auto Carrier Exhaustion Letter: A formal letter from the auto carrier confirming that Personal Injury Protection (PIP) and/or Medical Payments (MedPay) benefits have been fully exhausted.

If the claim is unrelated to a MVA:

• Medical records: Clinical documentation demonstrating that the injury or services rendered were unrelated to a MVA.

Submission guidelines

Contracted, in-network providers should submit documentation through the Devoted provider portal whenever possible. Documentation may also be submitted by fax or mail. Please see 'How to respond to medical record requests from Devoted' provided on this page for all submission method instructions.

Non-participating providers may submit documentation by fax or mail using the submission instructions listed provided on this page.

All documentation must meet the applicable timeframes outlined in the Provider Manual, including the Claims Timely Filing of Claims and Payment Disputes and Reconsiderations sections.

Please include:

• The claim number or reference number associated with the denial
• Member name and date of birth
• All supporting documentation relevant to the claim review

If submitted records are insufficient to determine whether services are unrelated to a motor vehicle accident or whether third-party benefits have been exhausted, the original denial may be upheld in accordance with Centers for Medicare & Medicaid Services (CMS) Medicare Secondary Payer (MSP) requirements and applicable Coordination of Benefits (COB) rules.

For more information on our claims process, visit our claims webpage.

Contact Us

Have questions? Call us at 1-877-762-3515, 8am to 5pm, local time.