Enhanced Claims Editing Processes

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Enhanced Claims Editing Processes


Starting on Sept. 1, 2021, EmblemHealth will expand our partnership with Cotiviti, Inc., a market leader in payment accuracy, for periodic post-payment reviews of paid medical claims. The post-payment reviews to be conducted are: Retrospective Accuracy datamining (RA) and Clinical Chart Validation DRG review (CCV). These are similar to reviews that are currently being conducted by Optum on behalf of EmblemHealth.

What you can expect: 

  • RA reviews are conducted to ensure correct reimbursement. These reviews rely on paid claims data to determine accuracy.
  • CCV reviews are conducted to ensure proper billing. These require a copy of the medical records, which may be requested if EmblemHealth has not already received the medical records.
  • If a claim is identified for either review, you will receive a letter identifying the claim(s) selected and be provided detailed information related to guidelines and time frames to follow.  

Cotiviti’s staff includes registered nurses, and medical and claims experts with varying expertise including, but not limited to, coding, claims operations, and quality. They work collaboratively with their clients and medical providers in creating effective strategies, plans, and activities to prevent future payment errors, and in improving the reimbursement process. You may already be familiar with Cotiviti as a leader in the industry with health plans across the U.S.


Cotiviti is a Business Associate of EmblemHealth as defined in 45 CFR, Section 160.103 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and will perform its responsibilities on behalf of EmblemHealth in full compliance with HIPAA requirements.


Consistent with this business relationship, we request your assistance in providing Cotiviti’s staff access to medical and/or financial information necessary to complete these reviews to the same extent EmblemHealth’s staff would be authorized to access such records.


Thank you for your cooperation. Please share this information with your staff. If you have questions about this update to EmblemHealth’s claims editing process, please contact us at 866-447-9717. We appreciate your participation in our network and your dedication to the health and welfare of our members and your patients.