CommercialAdministrativeHigh impact
High Dollar Pre-payment Review Update for Group and Individual Plans
BlueCross BlueShield of South Carolina·SC·Claims
Effective date
Jan 1, 2026
We identified it
Aug 20, 2026
Summary
Effective January 1, 2026, BlueCross BlueShield of South Carolina is lowering the High Dollar Pre-payment Review (HDPR) threshold from a higher amount to $75,000 or greater for inpatient institutional claims on Group and Individual plans. Hospitals must now submit itemized bills for any inpatient claim meeting this threshold (except those using per-diem, flat-fee, case rate, or DRG pricing). The itemized bill must include clear descriptions, medication names/doses, supply names, CPT/HCPCS codes, and revenue codes for each line item; charges identified as unbundled or non-reimbursable per the Inpatient Non-Reimbursable Charge/Unbundling Policy will be removed before payment processing.
Action Required
By December 31, 2025: (1) Billing team must identify all Group and Individual plan members using the provided alpha prefixes and group number prefixes (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) Update billing system to flag inpatient institutional claims with allowed amounts of $75,000 or greater for these plans. (3) Configure system to automatically require itemized bill submission through My Insurance Manager claims attachment feature for flagged claims. (4) Update billing staff training and encounter documentation templates to ensure providers submit itemized bills with complete line-item detail including: clear service/supply descriptions, medication names and doses, CPT/HCPCS codes, revenue codes, and legible formatting. (5) Establish internal workflow to review itemized bills against the Inpatient Non-Reimbursable Charge/Unbundling Policy before submission to identify and remove unbundled charges. (6) Ensure billing team does NOT submit medical records in lieu of itemized bills, as the insurer will not accept them. Failure to submit compliant itemized bills for claims meeting the $75,000+ threshold will result in claim denials or payment delays.