Health Plan Payment Integrity Audit Form
Complete this form to document a comprehensive audit of payment integrity for a health plan.
Health Plan Name
*
Payer Organization
*
Audit Period
*
Type of Audit
*
Pre-payment
Post-payment
Retrospective
Audit Scope
*
Claims Review
Provider Payment
Member Eligibility
Coding Accuracy
Other
Number of Claims Audited
*
Audit Findings
*
Rows
Number Identified
Total Value ($)
Overpayments
Underpayments
Denied Claims
Correct Payments
Corrective Actions Taken
*
Provider Notification
Claim Adjustment
Payment Recovery
No Action Needed
Other
Compliance Check
*
Compliant
Non-Compliant
Additional Comments or Notes
Reviewer Name
*
First Name
Last Name
Reviewer Email
*
example@example.com
Date of Audit Completion
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Audit
Should be Empty: