CommercialAdministrativeMedium impact
New Audit Requirements for Million-Dollar Claims
Highmark·PA, DE, NY, WV·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
Mar 30, 2026
Summary
Effective July 1, 2026, Blue Cross Blue Shield Association mandates comprehensive pre-payment audits for all claims of $1 million or more. Medical records must be submitted timely for these high-dollar claims or the claim will be denied.
Action Required
By July 1, 2026: Billing team must establish procedures to identify claims approaching $1 million and ensure timely submission of all requested medical records for pre-payment review. Update billing workflows to flag high-dollar claims for comprehensive audit preparation including itemized bills, DRG review, and clinical documentation. Failure to provide medical records according to Highmark policies will result in claim denial.