P.R. Laws tit. 26, § 9086
(a) Health insurance organizations or issuers and providers shall make every effort to resolve claim inquiries directly. The name, contact telephone number, and fax number of each representative of the health insurance organization or issuer or the provider shall be exchanged no later than at the time of billing for a provider and the point of first inquiry by a health insurance organization or issuer.
(b) If a satisfactory resolution of the questions surrounding the bill is not achieved by the representatives of the health insurance organization or issuer and the provider, then a full audit process may be initiated by the health insurance organization or issuer.
(c) Claim audits may require documentation from or review of a patient’s clinical record and other similar medical or clinical documentation. Clinical records exist primarily to ensure continuity of care for a patient. Therefore, the use of a patient’s record for an audit must be secondary to its use in patient care.
(d) All health insurance organization or issuer claim audits shall begin with a notification to the provider of the intent to audit. Notification to the provider by the qualified claim auditor shall occur within six (6) months following receipt of the final claim for payment by the health insurance organization or issuer. Once notified, the provider shall respond to the qualified claim auditor within thirty (30) calendar days with a schedule for the conduct of the audit. The qualified auditor shall complete the audit within thirty-six (36) months of receipt of the final claim by the health insurance organization or issuer. Each party shall make reasonable provisions to accommodate circumstances in which the schedule specified cannot be met by the other party. The health insurance organization or issuer shall not request nor accept audits after thirty-six (36) months from the date of receipt of the final claim. Provided, That it shall not be construed that the thirty-six (36) month term provided to complete the audit shall render ineffective shorter terms that have been agreed on for the same purposes under a contract. For purposes of the scope of the audit, the practice of extrapolating or projecting overpayment recovery from providers by the health insurance organizations, issuers, or third parties contracted by them in audits that find billing errors beyond the audited period is hereby prohibited.
(e) All claim audits shall be conducted on the premises of the provider, except in instances where a provider chooses to allow individual, reasonable requests for off-site audits.
(f) All requests for claim audits, whether by telephone, electronic or written, shall include the following information:
(1) The basis of the health insurance organization or issuer’s intent to conduct an audit on a particular bill or group of bills. When the intent is to audit only specific charges or portions of the bills, this information should be included in the notification;
(2) name of the patient;
(3) admit and discharge dates, if apply;
(4) name of the auditor and the name of the audit firm, if the health insurance organization or issuer has contracted with a third party to conduct the audit;
(5) Clinical record number and the provider’s patient account number, if known, and
(6) whom to contact to discuss the request and scheduled audit.
(g) Providers that cannot accommodate an audit request that conforms to these provisions shall explain, within a term that shall not exceed thirty (30) calendar days, why the request cannot be met. Along with the explanation, providers shall propose a new date to reschedule the audit, which shall not exceed forty (40) days as of the date of the original audit. Auditors shall group audits to increase efficiency whenever possible.
(h) It shall be the responsibility of the provider seeking payment of a claim or reimbursement to notify the auditor prior to the scheduled date of audit, if the auditor shall have problems accessing records. The provider shall be responsible for supplying the auditor with any information that could affect the efficiency of the audit once the auditor is on-site.
History —Aug. 29, 2011, No. 194, § 6.060, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 8, eff. 30 days after July 10, 2013.