Upcoming Post-payment Review Process Changes for Group and Individual Plans

IMMEDIATE: Billing team must (1) identify all claims for group numbers 61, 62, 64, and 65 submitted to BCBS-SC; (2) establish a process to track and respond to medical records requests from Cotiviti within 45 calendar days of receipt; (3) create internal documentation of appeal procedures and assign staff responsibility for first-level appeals to Cotiviti and second-level appeals to BlueCross; (4) update claim management system with flag/alert for these group prefixes; (5) notify hospital coding and clinical staff of the incoming review scope (short-stay admissions, DRGs, readmissions); (6) upon receipt of Cotiviti request letter: extract and compile medical records, document submission date and method, establish tracking for determination notification. BEFORE IMPLEMENTATION DATE (TBD): Contact Provider Relations Consultant for exact effective date and coordinate any system updates. Failure to respond within 45 days may result in automatic claim adjustment or denial without provider input.