Provider Audit and Special Investigations Unit (SIU) – Standard Review Policy

Policy Number: GP-X-028

Last Updated: Jan. 7, 2022 

Blue Cross and Blue Shield of Nebraska (BCBSNE) reserves the right to perform a review or audit of any item or service provided to covered persons to ensure medical record completeness, appropriate coding and billing, and that the items or services were medically necessary and provided in accordance with the member’s benefit plan, accepted medical practice standards, and BCBSNE medical and provider policies and contracts.  

Reviews may also be conducted as a part of BCBSNE’s Utilization Review Program. For example, a review may be part of a continued stay review, case management review, medical necessity review, DRG validation review or other review of items and services provided to members. These reviews may be conducted onsite, or BCBSNE may request documents to review at the BCBSNE site.  

Health care providers agree to cooperate and assist with these efforts. BCBSNE agrees to make every attempt to abide by reasonable and non-obstructive practices. Reviews and audits will be conducted by BCBSNE staff or designated vendors acting on behalf of BCBSNE.  

The review may include inspection and duplication of all medical and other records applicable to treatment of a covered person necessary to determine liability, medical appropriateness and/or to verify that items or services were rendered. Only medical records, itemized statements or other necessary items of BCBSNE-covered persons will be reviewed.  

BCBSNE reserves the right to require a physician, facility or other health care provider to comply with recommendations resulting from reviews or audits when noncompliance is identified.