High Dollar Pre-payment Review Update for Group and Individual Plans

By December 31, 2025: (1) Billing team must update internal processes to identify all inpatient institutional claims with allowed amounts ≥$75,000 for Group and Individual plans (prefix codes: BEQ/61, BEU/61, BXZ/62, CNN/62, CNS/62, MBX/62, MBY/61, NZB/64, PEQ/62, PEX/61, RBN/61, RBX/62, XBE/61, ZCF/61, ZCP/94, ZCU/62, ZCV/65, ZCX/63, ZCY/66). (2) Configure billing system to flag claims exceeding the $75,000 threshold that use pricing methodologies other than per-diem, flat-fee, case rate, or DRG rates for mandatory pre-payment review. (3) Establish workflow to generate and submit itemized bills through My Insurance Manager℠ with each line including: clear description, medication name/dose, supply names, applicable CPT or HCPCS codes, and revenue codes. (4) Ensure all itemized bill submissions are legible to prevent review delays. (5) Train billing and clinical staff that medical records cannot substitute for itemized bills. (6) Review the Inpatient Non-Reimbursable Charge/Unbundling Policy to understand which charges will be removed during review (general/administrative costs, routine equipment, routine disposable supplies listed in Tables 1-3). Failure to submit compliant itemized bills will result in claim processing delays and potential payment reductions.