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The Audit Process

Medical Record Audit

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PIAU performs medical record audits to verify that the services submitted by the provider to the Authority were provided and documented according to Oregon Medicaid rules and guidelines.

Providers are obligated to apply reasonable safeguards when transmitting Protected Health Information to OHA as outlined by the Policy for Protected Health Information (ORS 192.553) and federal Health Insurance Portability and Accountability Act (45 CFR parts 160 and 164).

​Once completed, OHA will send the Preliminary Matrix of Findings via certified mail to the provider for their consideration.

Frequently asked questions

How will I be notified of the audit findings?
Once the auditor reviews all the information from the provider, a Preliminary Matrix of Findings will be completed, and a copy submitted to the provider.  The provider will indicate their response on this matrix.
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​What if the provider finds documentation that was not previously submitted but would, if considered, support the services billed to OHA?
​The provider may submit additional documentation with their response to the Preliminary Matrix of Findings.​

OHA will send a request for medical records to the provider’s MMIS Mail-To address via certified mail. The request will include the following information:

  • Recipient's Name, ID and Date of Birth
  • The month of service for which records are requested.

OHA expects the provider to submit documentation that would support the claim as submitted to OHA and/or the CCO.

Frequently asked questions

​Do you really need the records for the entire month of service indicated?

Yes. The request is for all medical records you have on file for the recipient, for the month indicated.​

What if we can't provide all the records within the timeline outlined in the records request letter?
Please contact the assigned auditor as soon as possible to discuss options.​

Why are we being audited?​​
Audits occur for various reasons including referrals, billing patterns or random selection.

​If the provider has any comments on the preliminary findings, OHA will add the provider's response to the findings and issue a Final Matrix of Findings.

Frequently asked questions

What if I agree with the findings on this final report?
Pay the enclosed invoice and the audit will be closed.

What if I disagree with the findings on this final report?
The provider may request an appeal.

What if I agree but cannot make a single lump sum payment for the balance?
Contact the assigned auditor; reasonable payment plans are available.

Demand Audit

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PIAU performs demand audits to determine if charges to OHA and/or the coordinated care organization (CCO) were appropriate, particularly when a client has other health coverage that should pay first.

PIAU selects claims for this type of audit using a very narrow set of parameters.

​OHA will send a request for medical records to the provider’s MMIS Mail-To address via certified mail. The request will include the following information:

  • Recipient's Name, ID and Date of Birth
  • All health coverage resources billed by the provider

OHA expects the provider to submit documentation that would support the charges submitted to OHA and/or the CCO.

Frequently asked questions

We believe we are correctly reporting Third Party Liability. Why does this keep happening?
On UB-04 claims, the most common cause is entering payer information on the wrong line of Field Locator (FL) 50. Each line is for a specific type of payer. If the patient does not have a specific type of payer (e.g., Medicare or private insurance), leave those lines blank.

Sample of Field Locator 50 on the UB-04 paper claim form

​Once completed, OHA will send the Preliminary Matrix of Findings via certified mail to the provider for their consideration.

Frequently asked questions

How will I be notified of the audit findings?
Once the auditor reviews all the information from the provider, a Preliminary Matrix of Findings will be completed, and a copy submitted to the provider.  The provider will indicate their response on this matrix.

​What if the provider finds documentation not previously submitted that would, if considered, support the services billed to the Authority?
​The provider may submit additional documentation with their response to the Preliminary Matrix of Findings.​

​If the provider has any comments on the preliminary findings, OHA will add the provider's response to the findings and issue a Final Matrix of Findings.

Frequently asked questions

What if I agree with the findings on this final report?
Pay the enclosed invoice and the audit will be closed.

What if I disagree with the findings on this final report?
The provider may request an appeal.

What if I agree but cannot make a single lump sum payment for the balance?
Contact the assigned auditor; reasonable payment plans are available.