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Update to Prepayment Review of Institutional Inpatient BlueCard® Claims

Excellus BlueCross BlueShield would like to make you aware that the threshold for institutional inpatient BlueCard claims requiring prepayment review is being reduced from $250,000 to $200,000. Effective January 1, 2020, these claims received from participating acute-care providers with a total allowed amount over $200,000 must include an itemized bill.

We implemented the prepayment review process for institutional inpatient BlueCard claims with a total allowed amount over $250,000 on January 1, 2019, as communicated in the October 2018 and January 2019 issues of our Connection newsletter.

This prepayment review process applies to all institutional inpatient BlueCard claims, except:

  • Medicare Supplement and Medicaid lines of business

  • Claims priced at a per-diem, flat-fee case rate, or DRG rate without an outlier.
    Note: DRG claims with an add-on outlier will require an itemized bill upon receipt of the claim.

Any claim requiring prepayment review received without an itemized bill will be returned with a letter requesting the itemized bill.

Please share this important information with anyone within your facility who should be aware.

Thank you for the quality care and service that you provide to our valued members.

 
 
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