MA Provider Audit Program

Prepayment/Post-Payment Review 
Blue Cross and Blue Shield of Nebraska (BCBSNE) or designated vendors acting on behalf of BCBSNE can conduct prepayment and post-payment reviews to monitor and assess the accuracy of the diagnosis and procedure coding as well as to determine the medical necessity and appropriateness of the items or services provided.  
 
Medicare Advantage (MA) claims subject to prepayment and post-payment reviews include, but are not limited to:

• All MA claims with allowable charges amount ≥ $100,000 received prior to Aug. 1, 2025.
• All MA claims with allowable charges ≥ $50,000 received on or after Aug. 1, 2025.
• All MA Claims involving a transfer to an Acute Inpatient Facility from a lower level of care (such as Acute Rehab, SNF, LTACH)
• All MA inpatient interim claims.
• Randomly selected MA outpatient claims.
• Randomly selected MA inpatient claims.
• Randomly selected MA professional claims.

BCBSNE reserves the right to require a provider to submit medical records and itemizations supporting billed items and services with the claim.