05/20/2025

Health Alliance Plan

Health Alliance Plan Managed Care Committee Member

April Danish, CHONC - Newland Medical Associates

Claim Pattern Review Program for Professional Claims
Effective July 1, 2025, HAP will implement a claim pattern review program to conduct ongoing reviews of specific professional claims. This program will focus on:

• Claims with unusual coding utilization patterns
• Coding mismatches
• Billing activities that deviate from billing patterns of similar specialties

This new program affects claims for the following lines of business: HAP Commercial, HAP Medicare Advantage, ASO, and Alliance Health and Life.

We have partnered with Cotiviti for this program. Cotiviti will send a letter to practices to be included in this review requesting medical records and information to support specific claims, including, but not limited to:

• Office/progress notes/treatment records/procedure notes/surgical notes
• Medication list and administration records
• All clinical documentation by the treating provider that supports diagnosis/condition and CPT/HCPCS code billed
• Provider orders/prescriptions
• All test results/interpretations
• PCP referrals
• Consultation reports
• Patient health history/screening questionnaires
• Clinical Laboratory Improvement Amendments (CLIA) certification for lab tests performed in-office as well as identification of who performed the lab tests
• All documentation to support services billed

Cotiviti will perform a prepayment review to help ensure that the claim coding/billing is appropriate and supported by the medical record and other documentation. Certified coders and nurses will review claim data alongside patient claim history to ensure proper claims processing. To validate coding accuracy and payment integrity, their evaluations will follow industry-standard guidelines, including: AMA CPT codes, ICD-10, HCPCS, CCI, CMS processing manuals, and relevant state and federal regulations.

If requested medical record information is not received within 60 days of Cotiviti's initial request, claims will be denied. Late records will not be reviewed, and the claim will remain denied.

HAP will finalize and review claims based on Cotiviti's recommendations.

If you receive a letter from Cotiviti and have questions regarding the medical record information requested, please contact Cotiviti at 1-833-931-1789, weekdays, between 8:30 a.m. and 7:30 p.m., Eastern Time.

Reminder – Plans Offered Through HAP CareSource
Below is an outline of the plans offered through HAP CareSource.

Marketplace

• These plans are Commercial HMO. If you are participating in HAP HMO Commercial plans, then you are participating in the HAP CareSource Marketplace plans.
• Available in Genesee, Lapeer, Macomb, Oakland, Shiawassee & Wayne counties.
• These plans are on-exchange and have gold, silver, and bronze tiers. There are also chronic-condition health plans:
  
  • Diabetes (gold and silver)
  • Healthy Heart (gold and silver)
  • HDHP Preventive and Preventive (silver)

Medicaid

• Programs include: Medicaid, Healthy Michigan Plan, Children’s Special Healthcare Services, MIChild, & Health Care Coverage for People Impacted by Flint Water.
• Available in the following counties:
  
  • Clinton, Eaton, Genesee, Hillsdale, Huron, Ingham, Jackson, Lapeer, Lenawee, Livingston, Macomb, Monroe, Oakland, Sanilac, Shiawassee, St. Clair, Tuscola, Washtenaw, Wayne

MI Health Link

• Medicare-Medicaid plan available in Macomb & Wayne counties

Online Resources
You can verify eligibility and benefits; submit prior authorization requests; view claims, and more via the HAP CareSource secure portal. We offer a single sign-on from the HAP portal:

• Log in at hap.org with your HAP username and password.
• Select the HAP CareSource link.

You can find general information about prior authorization requirements, claims, provider manuals, and more when you visit hapcaresource.com, select Providers, and then the appropriate plan.

Reminder – Appeals Information
Appeals processes can be found online. Log in at hap.org and select Provider Manual under Quick Links.

Reminder – Benefit Coverage Policies
Log in at hap.org, select More, Benefit Admin Manual. You can easily search for policies by term, code, or phrase. To see changes from the previous month, select Recent Changes.

Reminder – Pharmacy Information
Prior authorizations
Choose the correct Request Type in the online application. There are a few choices related to specific drugs. Otherwise, you need to select a “DRUG-General Request” and ensure you are choosing the correct location for administration (home infusion, infusion center, or office).

Submitting Prior Authorization Requests for Part D Drugs
Electronically through CoverMyMeds platform Helping People get the Medicine They Need

Formularies
Visit www.hap.org/providers/provider-resources, select Formularies.

Policies
Log in at hap.org, select Resources, Working with HAP, Policies and Procedures.

Reminder – Preferred Lab Partner
Joint Venture Hospital Laboratories (JVHL) is a network of community hospital labs. JVHL offers lab services at most of HAP’s participating hospitals. HAP has an affiliation with JVHL as our preferred lab for Commercial HMO members. Providers are expected to use JVHL labs whenever possible. For more information on locations and services please visit the JVHL website.

Reminder – Keep It Updated in NPPES
It’s important to ensure your data in the National Plan & Provider Enumeration System (NPPES) is accurate. CMS is encouraging health plans to use NPPES as a resource for online provider directories. By using the NPPES database for provider directories, we could decrease the frequency we contact you for this information. To verify your information, log in at the NPPES website. When reviewing, pay close attention to:

• Provider name, mailing address, telephone & fax numbers
• Specialty and Taxonomy

Be sure to remove any practice locations no longer in use and only include addresses where:

• You practice and actively see patients
• Patients can call and make an appointment

Reminder! You can submit demographic updates directly to HAP via our Provider Change Form.

Reminder – Updating Your Profile – Training & Disability Accommodations
It’s important to let us know if your office has any specialized training and experience such as:

• Blindness/visual impairment
• Child welfare
• Chronic illness
• Co-occurring disorders
• Deafness/hard-of-hearing
• HIV/AIDS
• Homelessness
• LGBTQ+ health
• Physical disabilities
• Serious mental illness
• Substance abuse
• Trauma
• Does your location accommodate individuals with disabilities?

This information is added to your online provider directory information. ID Admins can easily update this information. Simply log in at hap.org, select Update Profile under your name in the upper right-hand corner.