What is a post-service, prepayment audit (PPM Audit)?
A. A PPM Audit (formerly known as Special Claims Review [SCR]) is a utilization control process that the Department of Health Care Services (DHCS) uses to ensure that providers are filing accurate Medi-Cal claims. Providers that are audited on a prepayment basis receive a letter explaining specific billing instructions necessary to pass professional medical review before claims payment. Claims subject to a PPM Audit must be submitted with documents required to substantiate the nature, extent and medical necessity of the services claimed. A PPM Audit is a post-service, prepayment audit of claims, established by Welfare and Institutions Code section (W&I Code ยง) 14133, subdivision (b). It does not constitute a sanction or punishment for misconduct, but instead is used by the DHCS to satisfy its oversight responsibilities.
Related Questions
- Who can a provider talk to for questions concerning post-service, prepayment audit (PPM Audit) documentation requirements for specific claims?
- Who can a provider talk to for other questions concerning the post-service, prepayment audit (PPM Audit) process?
- How can a provider appeal a specific claim denied by the post-service, prepayment audit (PPM Audit)?
