Post-Payment Audit

Policy Number: GP-X-031

Last Updated: Jan. 7, 2022 

Audit Process

The audit process can be a review of the itemized billing itself, a desk review at Blue Cross and Blue Shield of Nebraska (BCBSNE) of selected medical records, or an onsite audit of the medical records at the facility or office. The provider will be notified if a desk audit will be performed. If an onsite audit is performed, BCBSNE will contact the provider to schedule an appropriate audit date as soon as possible. BCBSNE will verify the mutually agreed upon audit date and time for an onsite audit. An itemized billing and any applicable provider audit work papers are generally requested prior to scheduling the audit.  

Itemized billings must be submitted within 30 calendar days of BCBSNE’s request, unless BCBSNE agrees to extend the due date. BCBSNE reserves the right to reverse the claim to deny if the provider fails to provide the itemized billing or initiate contact with BCBSNE to extend the due date.  

Itemized billings should be submitted in a spreadsheet format and include the following information:

  • Patient Name
  • Hospital Account Number
  • Date of Service
  • Revenue Code
  • Description of Item Billed
  • Units
  • Unit Charge
  • Total Amount Billed

The information provided in the spreadsheet should only reflect the charged amounts. Any overcharges or reversed charges should be removed.  

BCBSNE is under no obligation to provide DRG and Severity of Illness (SOI) information to the provider for approval to audit. BCBSNE is also under no obligation to provide a letter of intent to audit to the provider.  

Preliminary Report Sheet and the Final Summary of Adjustments

When an audit has been completed, a Preliminary Report Sheet is provided to the provider outlining the audit findings. The provider will then have up to 30 days to complete an exit interview and/or submit supporting documentation to defend any charges noted in the Preliminary Report Sheet. If no response is received at the end of 30 days, then the audit findings will stand as final. Either BCBSNE or the provider may request an onsite exit interview if desired.  

Onsite Exit Interview

If an onsite exit interview is requested, audit results will be reviewed with the provider within 30 days of completion of the audit findings.  

Upon completion of the exit interview, BCBSNE has 14 calendar days to return the Final Summary of Adjustments to the provider.  

After the receipt date of the Final Summary of Adjustments, the provider has 14 calendar days to file a written appeal. If an appeal is not received by close of business on the 14th calendar day, then the Final Summary of Adjustment will stand as final.