Why did the claim deny?
Use the below link to aid in determining why the claim denied and next steps.
BCBSND has enhanced our core claims processing with the Payment Integrity Program. The program will enhance current capabilities to ensure payments are correct, assigned to the right payer and consistent with national standards and guidelines.
We have partnered with Cotiviti, a leading health care analytics company, to bring a new level of accuracy to claims processing. This new enhanced level will supplement our core in-house system of robust checks and balances.
The Payment Integrity Program consists of Retrospective (post-pay) and Prospective (prepay) analysis of claims.
To learn more about the Payment Integrity Program, types of audits and timelines:
- View the Education on Demand (EOD) presentations
- Read the Frequently Asked Questions
Retrospective (post-pay)
Clinical Chart Validation (CCV)
Requires review of medical records including complex Diagnosis Related Group (DRG).
Retrospective Claims Accuracy (RCA)
Often related to provider billing issues, such as split bills and excessive units being billed.
Evaluation & Management (E/M)
This is a program that reviews level 4 and 5 E/M services on outlier providers.
COB Validation (COB)
Identifies when another carrier or entity should be responsible for paying on a claim.
- This follows BCBSND standard processes.
- Letter will come from BCBSND
Prospective (pre-pay)
Payment Policy Management (PPM)
Uses advanced data analytics to identify claims at an elevated risk for incorrect coding and claim reimbursement.
Coding Validation (CV)
A process within PPM where complex claims can be briefly paused and sent for clinical review.
Education on Demand video presentation
Education on Demand video presentations
faq
