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Update to Prepayment Review of Institutional Inpatient BlueCard® Claims

Audience: Participating Hospitals

We would like to make you aware that the threshold for institutional inpatient BlueCard claims requiring prepayment review is being reduced from $200,000 to $100,000. Effective January 1, 2021, these claims received from participating acute-care providers with a total allowed amount over $100,000 must include an itemized bill.

We previously reduced the threshold for institutional inpatient BlueCard claims requiring prepayment review to from $250,000 to $200,000 on January 1, 2020.

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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Excellus

Claims and Billing