CommercialAdministrativeHigh impact
Reminder: High Dollar Pre-payment Review Process
BlueCross BlueShield of South Carolina·SC · General Surgery, Cardiothoracic Surgery, Transplant Surgery +1 more·Claims
Effective date
Mar 3, 2026
We identified it
Aug 20, 2026
Summary
BlueCross BlueShield of South Carolina has activated a High Dollar Pre-payment Review (HDPR) process for inpatient institutional claims exceeding $100,000 allowed amount ($75,000 for Group/Individual plans). Hospitals must now submit itemized bills through My Insurance Manager for claims using non-standard pricing methodologies (excluding per-diem, flat-fee, and DRG rates). Itemized bills must include detailed line-item descriptions with medication names/doses, supply names, CPT/HCPCS codes, and revenue codes to avoid claim delays.
Action Required
Effective immediately (March 3, 2026): (1) Billing team must identify all BlueCross BlueShield of South Carolina inpatient claims with allowed amounts ≥$100,000 (or ≥$75,000 for Group/Individual plans) that use non-standard pricing. (2) For affected claims, billing team must prepare and submit itemized bills via My Insurance Manager claims attachment feature BEFORE initial claim submission. (3) Each itemized bill line item must include: medication/supply name, dose, applicable CPT/HCPCS codes, revenue codes, and clear descriptions. Ensure all submissions are legible. (4) Update internal billing workflows and claim submission checklists to flag high-dollar inpatient claims for mandatory itemized bill preparation. (5) Train billing staff to recognize which plan types trigger HDPR thresholds and which pricing methodologies require itemized bills. Do NOT submit medical records as a substitute for itemized bills. Non-compliance will result in claim processing delays and potential underpayment as charges are identified as non-reimbursable during review.