What must an auditor review to determine the provider's obligations under an insurance contract?

An auditor must review the rules the provider is bound to follow to determine the provider’s obligations under an insurance contract. These rules typically include the terms of the contract itself, which dictate the responsibilities of both the provider and the insurance company. Understanding these rules is essential for ensuring compliance with the specific expectations set forth in the insurance agreement, which may include coding requirements, coverage limitations, and claims submission processes.

In this context, examining the rules helps the auditor assess whether the provider is adhering to the contractual obligations, which is critical in identifying any potential compliance issues or billing discrepancies. A thorough understanding of these rules supports the auditor in making informed judgments about the legitimacy and appropriateness of the provider’s billing practices under the insurance contract.

While other factors like state healthcare laws, the insurance company's history, and maximum reimbursement rates may provide context and insights into the broader regulatory and financial environment, they do not specifically outline the direct obligations that a provider has in relation to an individual insurance contract. Thus, focusing on the rules helps pinpoint the relevant responsibilities that must be reviewed for compliance purposes.