Post-Payment Audit

Audit Process

The audit process can be a review of the itemized billing itself or a desk review at Blue Cross and Blue Shield of Nebraska (BCBSNE) of selected medical records. The provider will be notified if a desk audit will be performed.

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.