Prepayment Audit

High-Dollar Prepayment Review Audit Process  

The audit process for claims with allowed charges of $100,000 and above may include a review of the itemized billing and a desk review of selected medical records. The audit criteria is dollar-based, therefore the itemized billing and selected medical records must 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 30 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 $100,000 and above. Each interim itemized statement should be numbered at the top to identify which interim claim the itemized statement is for. Itemized statements must be submitted within 21 calendar days of BCBSNE’s request. BCBSNE reserves the right to return the claim if the provider fails to provide the itemized statement in a timely manner.
  
Final claims, not including interim claims, should not be submitted until all charges are accounted for to avoid unnecessary rework on both sides. Please ensure that corrected 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 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 must be submitted within 21 calendar days of BCBSNE’s request or the claim will be returned. 

Medical records must be submitted within 30 calendar days of BCBSNE’s request. BCBSNE reserves the right to deny the claim if the provider fails to provide the itemized medical records in a timely manner.