Cotiviti Frequently Asked Questions (FAQ)
1. General Information
What is Cotiviti?
Cotiviti is a nationwide healthcare payment accuracy company specializing in the review of inpatient claims. The 1199SEIU Benefit Funds have contracted with Cotiviti to provide pre- and post-pay diagnosis related group (DRG) and readmission (RAD) audit validation for inpatient services.
If I have questions about the audits, whom do I call?
Please contact 1199SEIU Benefit Funds/Cotiviti Provider Services at (770) 379-2373.
I did not receive a copy of the audit correspondence or it has been misplaced. How can I obtain a copy?
Please contact 1199SEIU Benefit Funds/Cotiviti Provider Services at (770) 379-2373, and they will mail you a copy.
When did Cotiviti begin audit validation for DRG and RAD inpatient claims?
Cotiviti began auditing claims from Aetna POS facilities on July 24, 2024. They began auditing claims from participating contracted facilities on February 1, 2025.
2. Medical Record Requests
How will I receive medical record requests from Cotiviti?
Through the mail, unless you’ve expressed a different preference. Call 1199SEIU Benefit Funds/Cotiviti Provider Services at (770) 379-2373 to let Cotiviti know which of the following methods you prefer:
- EMR (electronic medical record) extract
- Fax
How can I submit medical records to Cotiviti?
You are encouraged to submit records to Cotiviti via the online secure Provider Connection Portal:
- Visit ProviderConnection.cotiviti.com.
- Use the distinct claim request code provided in the record request letter to log into the portal.
- Upload your records.
As an alternative, you may submit records in one of the following ways, though the Provider Connection Portal is the preferred method for submitting medical records:
- Mailing/shipping hard copies
- EMR (electronic medical record) extract
- Fax
Details, including relevant addresses and phone/fax numbers, are included in the record request letter.
Can I mail paper copies of the medical records to Cotiviti?
Yes. Records may be mailed to Cotiviti via USPS or shipped via UPS or FedEx (or your preferred shipper). Neither Cotiviti nor the 1199SEIU Benefit Funds will reimburse the cost of mailing/shipping services.
Note: There are different addresses for participating contracted facilities and Aetna POS facilities.
Cotiviti
c/o Cotiviti – 6040
66 E. Wadsworth Park Dr., Box 12017
Draper, UT 84020
Cotiviti
c/o Cotiviti – 7050
66 E. Wadsworth Park Dr., Box 12017
Draper, UT 84020
Will Cotiviti accept medical records via a document management clearinghouse?
Yes, if Cotiviti also uses the same clearinghouse.
Do I need to send the entire medical record for a claim?
In most cases, no. The specific records needed are listed in the medical records request letter. If the requested records do not support reimbursement for the claim, please send any additional information necessary to support the claim as originally submitted.
What if I need more time to send the requested medical records?
If you are unable to provide the medical records within the 30-day timeframe due to extenuating circumstances, please contact 1199SEIU Benefit Funds/Cotiviti Provider Services at (770) 379-2373 Monday through Friday from 8:00 am to 5:00 pm Eastern. Cotiviti will review requests for additional time on a case-by-case basis.
What if I miss the deadline for submitting the medical records?
You should send the medical records to Cotiviti even if the deadline has passed. The audit will be conducted once Cotiviti receives the records. Failure to submit the requested medical records may result in an administrative claim denial and recoupment of claim payments. However, if such a denial is issued, you should still send the medical records, as Cotiviti will conduct the audit once medical records are received.
We would like medical record requests sent to a different name or address at our organization. How do we request this?
You may submit your request by mail, fax or phone. To submit your request by phone, call the Cotiviti Retrieval Operations Center at (833) 931-1789.
To mail or fax your request, write or fax to:
Cotiviti
c/o Cotiviti – 6040
66 E. Wadsworth Park Dr., Box 12017
Draper, UT 84020
(800) 316-3689
Cotiviti
c/o Cotiviti – 7050
66 E. Wadsworth Park Dr., Box 12017
Draper, UT 84020
(888) 322-8689
3. Audit Determinations
What happens after Cotiviti receives our medical records?
Cotiviti reviews the claim and the medical records to assess the coding, DRG assignment and RAD visit. An audit determination letter is mailed to you (the provider) after the requested medical records are received and the audit results in a change finding.
What coding references are used for Cotiviti audit determinations?
Cotiviti audits are based upon national correct coding standards in the ICD-10-CM/PCS Official Guidelines for Coding and Reporting. These guidelines have been approved by the organizations that make up the cooperating parties for ICD-10-CM/PCS: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). These guidelines are interpreted in the ICD-10-CM/PCS Coding Clinic published by the AHA. Medical necessity reviews reference nationally recognized guidelines, such as InterQual® Guidelines for Acute Care: Adult and Pediatrics and MCG (previously known as Milliman Care Guidelines).
When does Cotiviti inform the 1199SEIU Benefit Funds of the audit results?
Typically within about 30 days of receiving the medical records.
What if I disagree with the audit determination?
If you disagree with the determination, you may submit an appeal to Cotiviti by following the instructions in the audit determination letter. You can submit your appeal through the secure Provider Connection Portal (ProviderConnection.cotiviti.com). You will need the claim request code in your determination letter to log in. As an alternative, you may mail your appeal request. When submitting your appeal, be sure to include additional documentation to support the request.
If a claim was not correctly coded and I agree with the audit determination, should I send a refund or corrected claim to Cotiviti?
No. It is not necessary to send a corrected claim or refund. The 1199SEIU Benefit Funds will be notified when the audit is complete and will apply a payment adjustment in accordance with the audit results (if applicable).
What if I do not respond to a DRG/RAD change determination?
If no response is received, the 1199SEIU Benefit Funds will assume you agree with the audit determination and the original payment will stand.
We would like audit determinations sent to a different name or address at our organization. How do we request this?
Please submit changes in writing. Cotiviti will verify the information with the 1199SEIU Benefit Funds before making the change.
Cotiviti
c/o Cotiviti – 6040
731 Arbor Way, Box 12017
Blue Bell, PA 19422
Cotiviti
c/o Cotiviti – 6500
731 Arbor Way, Box 12017
Blue Bell, PA 19422
Can I speak to the auditor who performed the audit?
You may discuss audit results with 1199SEIU Benefit Funds/Cotiviti Provider Services by calling (770) 379-2373. It is not guaranteed, however, that you will be able to speak with the auditor who conducted the audit.
4. Requests for an Appeal
Does Cotiviti handle appeals?
Cotiviti handles first- and second-level appeals on the 1199SEIU Benefit Funds’ behalf. You may submit appeals and provide additional documentation to support your appeal through the secure Provider Connection Portal (ProviderConnection.cotiviti.com). You will need the claim request code provided in the determination letter to log into the portal.
As an alternative, you may mail your appeal requests and supporting documentation to:
Cotiviti
c/o Cotiviti – 6040
731 Arbor Way, Box 12017
Blue Bell, PA 19422
Cotiviti
c/o Cotiviti – 6500
731 Arbor Way, Box 12017
Blue Bell, PA 19422
Can I fax an appeal?
No. Appeals must be submitted online or through the mail.
What is the timeframe for submitting a first-level appeal?
90 days. If you are submitting an appeal, you must do so in writing within 90 days of Cotiviti’s audit determination letter. You should include additional documentation to support your appeal. Cotiviti will issue an appeal response within 30 days.
What happens if I do not submit a first-level appeal within the specified timeframe?
If a first-level appeal is received after the specified timeframe, or if no appeal is received, the original audit determination is upheld.
What if I disagree with the first-level appeal determination?
You may file a second-level appeal. Cotiviti accepts second-level appeal requests and supporting documentation via the secure Provider Connection Portal (ProviderConnection.cotiviti.com). You will need the claim request code included in the first-level appeal determination letter to log in.
As an alternative, you may send your second-level appeal request and supporting documentation to Cotiviti at:
Cotiviti
c/o Cotiviti – 6040
731 Arbor Way, Box 12017
Blue Bell, PA 19422
Cotiviti
c/o Cotiviti – 6500
731 Arbor Way, Box 12017
Blue Bell, PA 19422
What is the timeframe for submitting a second-level appeal?
90 days. If you are submitting a second-level appeal, you must do so in writing within 90 days of Cotiviti’s first-level appeal determination letter. You should include additional documentation to support your appeal. Cotiviti will issue an appeal response within 30 days.
What happens if I do not submit a second-level appeal within the specified timeframe?
If a second-level appeal is received after the specified timeframe, or if no appeal is received, the first-level appeal determination is upheld.
What if I disagree with the second-level appeal determination?
You have a right to request a third and final appeal. However, Cotiviti does not accept third-level appeals. All third-level appeals should be sent to and are reviewed by Island Peer Review Organization (IPRO), a third-party external utilization management organization the 1199SEIU Benefit Funds have retained. This independent review is a voluntary third-level review program, and IPRO charges a fee for the review. Instructions for submitting a third-level appeal are in the second-level appeal determination letter, and the contact information is also included at the end of this FAQ.
What is the timeframe for submitting a third-level appeal?
90 days. If you are submitting a third-level appeal to IPRO, you must do so in writing within 90 days of Cotiviti’s second-level appeal determination letter. You should include documentation to support your appeal. IPRO will issue an appeal response.
What happens if I do not submit a third-level appeal within the specified timeframe?
If a third-level appeal is received after the specified timeframe, or if no appeal is received, the second-level determination is upheld.
What if I disagree with the third-level appeal determination?
The 1199SEIU Benefit Funds deem the third-level appeal determination to be final and binding. No further appeal is granted.
5. Quick Reference Guide to Cotiviti CCV Letters
| Letter Name | Timeframe for Provider Response | Description |
|---|---|---|
|
Request for Medical Records
|
30 days
|
This is the initial letter notifying you of the audit and requesting medical records. You have 30 days to send the records to Cotiviti.
|
|
Second Notice: Request for Medical Records
|
30 days
|
This is the second and final request for medical records. You have 30 days from the date of this notice to send the records to Cotiviti.
|
|
Audit Determination—Change
|
90 days
|
This letter is sent when Cotiviti completes its audit and determines a change to the DRG or RAD visit.
If you disagree with the audit determination and want to file a first-level appeal, you must do so within 90 days.
|
|
First-level Appeal Response—Upheld
|
90 days
|
This letter is sent when Cotiviti completes its first-level appeal review and upholds the original audit determination.
If you disagree with the first-level appeal response and want to file a second-level appeal, you must do so within 90 days.
|
|
First-level Appeal Response—Overturned
|
N/A
|
This letter is sent when Cotiviti completes its first-level appeal review and overturns the original audit determination, agreeing with the coding originally submitted by the provider. No further action is required.
|
|
First-level Appeal Response—New Determination
|
90 days
|
This letter is sent when Cotiviti completes its first-level appeal review and makes a new determination based on information submitted by the provider during the first-level appeal process.
If you disagree with the first-level appeal response and want to file a second-level appeal, you must do so within 90 days.
|
|
Second-level Appeal Response—Upheld
|
90 days
|
This letter is sent when Cotiviti completes its second-level appeal review and upholds the first-level appeal determination.
If you disagree with the second-level appeal response and want to file a third-level appeal, you must do so—with IPRO, not Cotiviti—within 90 days.
|
|
Second-level Appeal Response—Overturned
|
N/A
|
This letter is sent when Cotiviti completes its second-level appeal review and overturns the first-level appeal determination, agreeing with the coding originally submitted by the provider. No further action is required.
|
|
Second-level Appeal Response—New Determination
|
90 days
|
This letter is sent when Cotiviti completes its second-level appeal review and makes a new determination based on information submitted by the provider during the appeal process.
If you disagree with the second-level appeal response and want to file a third-level appeal, you must do so—with IPRO, not Cotiviti—within 90 days.
|
6. Contact Information for Cotiviti Audits
1199SEIU Benefit Funds/Cotiviti Provider Services
Monday – Friday, 8:00 am – 5:00 pm ET
Phone: (770) 379-2373
Fax: (800) 316-3689
Cotiviti Retrieval Operations Center
Monday – Friday, 6:30 am – 5:30 pm MT
Phone: (833) 931-1789
Fax: (800) 316-3689
Medical Record Submission
For claims related to participating contracted facilities:
Cotiviti
c/o Cotiviti – 6040
66 E. Wadsworth Park Dr., Box 12017
Draper, UT 84020
For claims related to Aetna POS facilities:
Cotiviti
c/o Cotiviti – 7050
66 E. Wadsworth Park Dr., Box 12017
Draper, UT 84020
First- and Second-level Appeals
For appeals from participating contracted facilities:
Cotiviti
c/o Cotiviti – 6040
731 Arbor Way
Box 12017
Blue Bell, PA 19422
For appeals from Aetna POS facilities:
Cotiviti
c/o Cotiviti – 6500
731 Arbor Way
Box 12017
Blue Bell, PA 19422
Third-level Appeals
IPRO
Attn: Director
1979 Marcus Avenue, 1st Floor
Lake Success, NY 10042
Fax: (516) 326-1034