Reminder: High Dollar Pre-payment Review Process

Immediately: Billing team must implement the following for all BlueCross BlueShield of South Carolina inpatient claims: 1. SCREENING: Flag all inpatient institutional claims with allowed amounts ≥$100,000 (or ≥$75,000 for Group and Individual plan members) that use discount-based pricing (i.e., exclude per-diem, flat-fee case rate, and DRG-based pricing). 2. DOCUMENTATION PREPARATION: For flagged claims, prepare itemized bills that include: - Clear line-item descriptions - Medication names and doses - Supply names - CPT codes, HCPCS codes, and revenue codes for each line item - Legible formatting to prevent review delays 3. SUBMISSION: Submit itemized bills through My Insurance Manager using the claims attachment feature before claim submission. 4. WORKFLOW UPDATE: Update billing system workflows and staff training to ensure compliance. Do NOT submit medical records in lieu of itemized bills—they will not be accepted. 5. PLAN IDENTIFICATION: Cross-reference member plan type and group number against BlueCross BlueShield alpha and group number prefixes to confirm HDPR applicability. Consequence of non-compliance: Claims will be delayed during pre-payment review, charges may be reduced based on the Inpatient Non-Reimbursable Charge/Unbundling Policy, and reimbursement may be denied or reduced.