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BCBS IllinoisCommercial · Administrative · Reimbursement · ILHigh impact

CERIS To Conduct Post-Payment Reviews on Claims

Effective date
May 1, 2026
Identified
Jun 16, 2026

Summary

Beginning May 1, 2026, CERIS will conduct post-payment audits on select commercial claims to verify accurate coding and DRG assignment. Providers may receive medical record requests and could face refund demands if documentation doesn't support the billed DRG.

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What to do

Action · 3 steps
01Before May 1, 2026: Billing team and providers must ensure all DRG assignments are fully supported by clinical documentation.
02Review current documentation practices for inpatient claims to ensure diagnosis and procedure codes match medical records.
03Establish workflow to respond promptly to CERIS medical record requests with required documentation and timelines.
If missed: Failure to provide adequate documentation may result in refund requests or payment adjustments.

Original notice

CERIS To Conduct Post-Payment Reviews on Claims
bcbsil.com · Always check the source before changing claims.
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