Reminder: We’ll Conduct Postpayment Reviews on Medicaid Claims

Oct. 1, 2026

As previously communicated, beginning Oct. 2, 2026, we’ll conduct postpayment reviews of Medicaid member claims to help identify billing inconsistencies and ensure coding accuracy and reimbursement policy alignment.

We’ll review current claims, claims within the applicable Medicaid recoverable lookback period and prospective claims submitted after program implementation.

All postpayment recovery edits for the Medicaid line of business are rule-based edits from Medicaid and Centers for Medicare & Medicaid Services provider guidelines or professional coding guidelines. Edits were additionally refined to align with professional organizations. 

Important reminder: The Medicaid recoverable lookback period for these reviews will be for claims paid on Jan. 1, 2026, and onward.

What happens next? After the review, you’ll receive written notification outlining the findings. If the review determines that payments aren’t supported by the submitted documentation, we may request a refund or apply an adjustment to future claim payments. The notification will include information on next steps or reconsideration options.

Join us for a limited webinar series for our Medicaid-contracted providers to learn about the new postpayment review process. 

Watch News and Updates for future updates.

If you have questions, please contact your Provider Relations Representative.