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Provider Action To Be Taken Following the Provider-Based Mid-Build Audit

The off-campus PBDs that were “mid-build” prior to 11/2/2015 received mid-build determination letters in January from CMS mid-build audit contractor, Cahaba Safeguard Administrators. 

For PBDs that received mid-build approval letters, they should bill with the “PO” modifier and thus receive the full OPPS rate. If the PBDs billed using the “PN” modifier while waiting for the mid-build determinations, the provider should identify all the claims that were underpaid and adjust the relevant PBD claim lines as follows:

  • For services rendered within the prior 12 months of the adjustment date, providers will adjust the PBD claim lines using the “PO” modifier. Also include “mid-build audit” in the claim remarks (Page 07).
  • For services rendered more than 12 months before the adjustment date, the providers will first reopen* the claims and then adjust the PBD claim lines using the “PO” modifier. Also, include “mid-build audit” in the claim remarks (page 07).

For PBDs that received mid-build disapproval letters, they should bill with the “PN” modifier and thus receive a partial OPPS rate. Providers shall, within 240 days (eight months) of receipt of the disapproval letter, repay any overpayment amounts to National Government Services. The provider should identify all the claims that were overpaid and either adjust all incorrectly submitted claims or submit a voluntary refund check to NGS with the listing of claims. 

  • If providers choose to adjust all incorrectly submitted claims to address its overpayments, the MACs shall instruct the providers to adjust the claims as follows:
    • For services rendered within the prior 12 months of the adjustment date, providers will adjust the PBD claim lines using the “PN” modifier. Also, include “mid-build audit” in the claim remarks (Page 07).
    • For services rendered more than 12 months before the adjustment date, the providers will first reopen* the claims and then adjust the PBD claim lines using the “PN” modifier. Also, include “mid-build audit” in the claim remarks (Page 07).
  • If providers choose to submit a voluntary refund check with the list of claims overpaid, refer to our website for instructions on voluntary refunds. Include reference to the mid-build audit determination in your voluntary refund submission.

For tracking purposes, providers should submit to NGS a written confirmation of the self-assessment, identified overpayment amounts, and date(s) of return of any overpayments to NGSProvBasedDeterminations@anthem.com.

*To reopen claims, provider will submit their adjustments using bill type frequency code “Q.” For example 13Q TOB.