Payment Integrity Operations Handbook for Health Plans

A reference-grade operating system for payment integrity work

Payment integrity decisions are only as defensible as the rules, evidence, ownership, and dates behind them. This handbook is built for health-plan teams that need a documented way to move from prepayment edits to DRG validation to overpayment recovery without relying on tribal knowledge, stale job aids, or one analyst's memory of what a rule used to require.

The scope stays deliberately on the payer side of the claim. It is written for payment integrity analysts and managers, Special Investigations Unit staff, claims-audit vendors working for health plans, and provider-network staff who need to understand how a denial, validation finding, or recovery file should be structured and supported.

The book starts by establishing an authority hierarchy and a source-and-version discipline. From there, it shows how to classify the work before action begins, confirm the required source documents, assign owners and reviewers, and preserve the reasoning behind each decision.

• Prepayment edit sequencing, including NCCI PTP and Medically Unlikely Edit concepts, payer-specific layers, stop points, and handoffs
• DRG validation checkpoints for principal and secondary diagnosis coding, procedures, MCC/CC effects, coding coordination, and clinical escalation
• Overpayment identification, calculation approaches, recovery notices, provider responses, reconciliation and closure
• Exception handling for missing or conflicting information, disputed cases, automated-review constraints, and professional-review triggers
• Record inventories, evidence mapping, retention considerations, competency checks, audit sampling, corrective-action aging, and management metrics
• A 30/60/90-day implementation sequence supported by registers, checklists, worksheets, logs, matrices, decision trees, and completed cases

Six recurring fictional claim scenarios show how the same operating logic behaves under different conditions. The cases move from a clean routine claim through incomplete documentation, a coverage dispute, a unit or modifier issue, an audit request, and a corrected-claim recovery, using one consistent fact pattern.

The emphasis is not on memorizing a printed threshold or using a book as a permanent source of truth. The handbook repeatedly routes the reader back to current statutes, regulations, payer policies, coding guidance, and organizational procedures, with a source-and-version register that makes updates visible. Clinical, legal, coding, and compliance judgment stays with the qualified professionals responsible for those decisions.

This is for organizations that want payment integrity work to be traceable from intake through closure. Whether the immediate need is tightening prepayment edit handling, standardizing DRG validation, documenting recoveries, training analysts, or preparing evidence for an internal or external challenge, the book provides a structured operating framework designed to be adapted to the plan's own policies, contracts, jurisdictions, and approval chain. The result is a practical framework for consistent decisions, documented handoffs, and review-ready evidence.