Post-Payment DRG Clinical Validation Audits

February 21, 2023
Post-Payment DRG Clinical Validation Audits

Beginning February 1, 2023, QualChoice will perform post-payment DRG clinical validation audits of facility claims.

QualChoice will perform these audits in conjunction with CERIS, a healthcare claims review service, to ensure that the DRGs billed correlate to the diagnostic, procedural, and discharge status coded in the patient’s medical record, on a post-payment basis. 

Claims should be billed and coded according to QualChoice’s policies and industry-standard coding guidelines for the bill type. This includes the Uniform Billing Editor, AMA, CPT®, CPT® Assistant, HCPCS, DRG guidelines, the CMS National Correct Coding Initiative (NCCI) Policy Manual, NCCI table edits, and other applicable CMS guidelines.

QualChoice or CERIS may contact you to request documentation, such as medical records, to conduct the post-payment audit. Once you have been contacted, please make sure to submit the requested information within seven calendar days. 

If you have any questions about the post-payment DRG audit, contact QualChoice’s provider relations team at 1-800-235-7111 ext. 7004. You can also email them at