New Audit Programs Vendor EXL

Date: April 27, 2023

Attention: All Providers

Effective Date: April 26, 2023

Call to action: Texas Children’s Health Plan (TCHP) Controls and Compliance (CC) would like to let providers know that TCHP has contracted with an external auditor, ExlService.com (EXL) to support its upcoming audit efforts. For your awareness, TCHP’s CC is organized within the Office of General Counsel under the Controls and Compliance Department.

EXL is currently conducting audits, and will introduce the following new audit programs starting April 26, 2023:

• High Cost Drug – a review process to ensure the dosage administered is billed appropriately. In addition to validation of units, the auditor reviews the coding of the drug to ensure the correct HCPCS is billed.
• Durable Medical Equipment – a review process to ensure the services provided were ordered by a provider, appropriately invoiced and accurately paid.
• Outpatient – a review process to ensure the coding is documented and billed appropriately.

How this impacts providers: TCHP kindly asks that in the instance providers are selected for these audits by EXL, that you please comply accordingly. For those providers chosen for these audits, they will receive an audit letter from EXL requesting medical records for a specific timeframe of date of service (DOS).

Next steps for providers: Providers are encouraged to share this communication with their staff and be on the lookout for a potential audit notification letter from EXL.

If you have any questions regarding these types of audits, please contact EXL at (833) 717-0378.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.