Providers should make sure their documentation is complete, accurate, easy to review, and consistent with the services billed. Strong documentation can help reduce the risk of audit findings, claim denials, payment delays, or recoupments.

Each year, between August and November, the Maryland Department of Health conducts encounter data validation audits. These audits compare selected medical records with submitted claims to confirm that billing details are accurate and properly supported.

What Providers Should Know

Before the audit begins, the state will send letters to billing providers of managed care organizations requesting medical records for selected claims.

The state’s auditor, Qlarant, may also contact providers by phone or fax if additional information or follow-up documentation is needed.

During the review, medical records are compared with the related claims to confirm that the procedure codes, diagnosis codes, and revenue codes match the care documented in the record.

What Providers Should Do

Providers should keep medical records complete, organized, and available in either paper or electronic format. Records should be clear, legible, and detailed enough to show the services that were provided.

Requested records must be submitted within the timeline set by the state. Some urgent requests may require a turnaround time of 48 hours, so providers should be prepared to respond quickly.

Claim Submission Best Practices

To help avoid audit issues, denials, or repayment requests, claims should closely match the member’s medical record.

Make sure billed services are supported by proper documentation, diagnosis and procedure codes are accurate, and the amount billed reflects the services actually provided.

Supporting Resources

For more guidance, providers can review the Maryland Provider Care Manual or visit the claims, billing, and payments section for information on medical record requirements, billing practices, and audit expectations.