[
AmeriHealth, through written agreements with its participating providers,
may conduct provider credit balance audits. Credit balance audits are performed
by health insurance payers, or the payer's authorized agent, to identify and
resolve facility provider accounts that contain a credit balance. These
accounts may contain a credit balance due to a number of reasons, including,
but not limited to, duplicate or similar claim payments, coordination of
benefits issues, workers' compensation coverage, automobile insurance coverage,
or misapplied contractual allowances.
If your facility is selected for a credit balance audit, you may be asked to
submit a credit balance report to AmeriHealth. A credit balance report should
include as many of the following data elements as possible:
- patient's full name
- patient's date of birth
- plan code
- the AmeriHealth certification number
- document control number (DCN) or claim number
- patient account number
- dates of service (both the admission and discharge dates)
- hospital department service (patient account financial class)
- diagnosis related grouper (DRG) (inpatient account)
- total charges
- patient payment
- total payment
- third-party payment
- total adjustment
- other adjustment
- deductions
- amount of credit balance
- aging buckets (e.g., 1 ? 30 days, 31 ? 60 days)
In addition to the above data elements, AmeriHealth may require view-only
access to the facility's patient accounting system and a copy of the facility's
allowance codes and patient accounting financial class.
AmeriHealth is committed to working with facilities in an attempt to resolve
credit balances in a quick and nonintrusive manner. Resolving credit balances
will benefit facilities through reconciliation of their accounts, in addition
to helping health care payers control premium costs for their membership.
For additional information regarding credit balance audits, please refer to
your Managed Care Hospital Agreement and AmeriHealth Member Hospital
Agreement.
]