Prepayment Audit

General
Policy Number: GP-X-030

Last Updated: Sept. 26, 2022 

High-Dollar Prepayment Review Audit Process

The audit process for claims with allowed charges of $100,000 and above can include a review of the itemized billing and a desk review of selected medical records, if received on or after Jan. 1, 2021. The audit criteria is dollar based, therefore, the itemized billing and selected medical records need to be submitted regardless of Blue Cross and Blue Shield of Nebraska (BCBSNE) primacy. 

All claims, including DRG claims with outliers that have allowable charges of $100,000 and above will require itemized statements. Itemized statements need to be submitted via secure email to HDPR@NebraskaBlue.com. Claims will not be processed until itemized statements are received. The billed charges total within the itemized statements must match the submitted claims. Failure to submit required itemized statements as requested and within the specified requested timeframe will significantly delay processing. The member ID must be included in the body of the email and must match the member ID on the submitted claim. Each itemized billing should be sent in a separate email. 

Medical records must be submitted within 21 calendar days of BCBSNE’s request. BCBSNE reserves the right to deny the claim if the provider fails to provide the medical records in a timely manner. 
 
Itemized billings should be submitted in a pivot table 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. 

Itemized statements for interim bills must include all charges for the dates of service in which the allowable amount is at $100,000 and above. Each interim itemized statement should be numbered at the top to identify which interim claim the itemized statement is for.  

Final claims, not including interim claims, should not be submitted until all charges are accounted for to avoid rework on both sides. Please ensure that correct or replacement claims do not contain any of the items or charges removed in a Summary of Adjustments. The appeal process outlined in Member Benefit Appeal and Reconsideration should be followed if a payment dispute arises. The continuous resubmission of removed items or charges may result in corrective action, including termination from the network in accordance with the terms of the provider contract.  

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. 

Standard Prepayment Audit Process  

The audit process can include a review of the itemized billing and a desk review of selected medical records. 

Itemized billings and medical records must be submitted within 21 calendar days of BCBSNE’s request. BCBSNE reserves the right to deny the claim if the provider fails to provide the itemized billing or medical records in a timely manner.