The contractor shall ensure
that each response to every piece of correspondence includes a detailed
outline of all actions taken to resolve the problem(s) and includes,
as appropriate:
• An explanation of the requirements
leading to the benefit determination;
• A clear, complete response
to all stated or implied questions;
• When necessary to support the
action taken, copies of Explanation(s) of Benefits (EOBs), claim
number(s) of the original claim(s), and the claim number(s) of adjustment
claim(s) including sufficient details to establish an easily followed
audit trail;
• Other documents necessary for
full explanation and clarity;
• Clear explanation of any additional
actions that require an action or reply by the inquirer before the
contractor can take final action on the matter; and
• A referral form to the contractor’s
PI Unit if potential fraud or abuse is identified. A copy of the
referral shall be filed with the correspondence.