Prepayment Reviews on BlueCard Inpatient DRG Claims
Beginning July 1, 2021, the Blue Cross and Blue Shield Association will require Blue Cross and Blue Shield of Texas (BCBSTX) to review select inpatient, diagnosis-related group (DRG) claims before processing. The review will check compliance with ICD-10 procedure coding system guidelines. For those claims, providers must submit medical records for the claim to process.
Which claims: This is for inpatient, DRG claims for services rendered to any hosted BlueCard member. Hosted BlueCard members are members of any Blue Cross and Blue Shield plan outside Texas receiving health care services in Texas.
What’s next: If we review your claim and find an error in how it’s coded in relation to the diagnosis, you’ll receive a letter that explains the review and the outcome.
How to submit medical records: When you are notified a claim is selected for review, you may be requested to submit medical records. You can submit them electronically using our Claim Inquiry Resolution tool. Include the corresponding claim number for quicker review and turnaround time.
Checking eligibility and benefits and/or obtaining benefit preauthorization/pre-notification or predetermination of benefits is not a guarantee that benefits will be paid. Payment is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations and exclusions set forth in your patient’s policy certificate and/or benefits booklet and/or summary plan description. Regardless of any benefit determination, the final decision regarding any treatment or service is between you and your patient. If you have any questions, please call the number on the member’s BCBSTX ID card.