TAKE NOTE: EFFECTIVE JULY 1, 2006, NHP was required to implemented Regulation 98 fraud and abuse requirements. NHP contracted with Ingenix to perform the Fraud and Abuse review and investigation. Ingenix will review claim history files. Once NHP reviews the initial findings based on claims history, under our Business Associate Agreement with Ingenix they are authorized to request medial records on our behalf and bound by HIPAA confidentiality rules. Therefore, Ingenix may contact you to request medical records to perform claim and medical record reviews. If you have any questions regarding this process, please call Provider Services at 1-800-558-7970.

To clarify what the process will be used to identify upcoding of services or unbundling of services, Ingenix utilizes CMS' National Correct Coding software to identify unbundled services, and applies the AMA's Correct Coding Guidelines to identify services that could be potentially upcoded. The definition for upcoding is when there are two or more options for the same procedure that vary depending on the severity of the patient's condition, the amount or size of the work to be done, or the number of steps to the procedure, and a provider bills a higher level when a lower level of service was received.