Introducing Claim Pattern Review Program from Cotiviti

Starting August 1, 2026, Healthfirst will implement Cotiviti’s Claim Pattern Review Program to conduct ongoing reviews of specific professional claims. This program will impact claims submitted by professional practitioners/practices for services rendered to patients enrolled in all lines of business. Claims may be selected based on unusual coding utilization patterns, coding mismatches, or billing activities that deviate from billing patterns of similar specialties.

What is the Claim Pattern Review Program?

Cotiviti’s Claim Pattern Review program is a type of prepayment review to ensure that claim coding and billing is appropriate and supported by the member’s medical record and other documentation.

As part of this process, certified coders and nurses will review claim data alongside patient claim history to ensure proper claims processing. Their evaluations will follow industry-standard guidelines, including AMA CPT codes, ICD-10, HCPCS, CCI, CMS processing manuals, and relevant state and federal regulations to validate coding accuracy and payment integrity. While this program is not focused on questions of medical necessity, but rather coding and billing accuracy compared to medical record documentation, Healthfirst reserves the right to add a medical necessity review by a Healthfirst physician if necessary.

What Actions Do Providers Need to Take?

Cotiviti will begin mailing letters to practices that have been identified for inclusion in this program on or after August 1, 2026.

As part of this program, Cotiviti will request medical record information in response to certain submitted 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 the 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
• Any other documentation supporting services billed

Providers who receive a letter will need to submit records at SubmitRecords.com or fax them to 1-800-269-7573. The letter will include a unique password that is required for records submission.

If requested medical record information is not received within 30 days of Cotiviti's request, identified claims will be denied. 

Claim processing details and appeals information, as appropriate, will be included in the Explanation of Payment (EOP) we generate following the processing of each impacted claim.

More Information

Introducing Coding Validation from Cotiviti

Questions?

If you receive a letter from Cotiviti and have questions regarding the medical record information requested, please contact Cotiviti at 1-833-931-1789, Monday to Friday, 8:30am and 7:30pm, ET.

For all other questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am-5:30pm.

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”).