Non-migrated member information
The contents of this page apply to non-migrated members, which includes Medicaid Expansion and FEP. For more information about migrated members, please use the Provider Support Hub.
BCBSND applies claim-processing edits for enhanced claims review process, formerly known as the payment integrity program. The edits ensure payments are correct, assigned to the right payer and consistent with national standards and guidelines.
We partner with a leading healthcare analytics company to review claims and bring an additional level of accuracy and analysis to claim processing. This enhanced level supplements our core in-house system of robust checks and balances.
When claims are affected by the edits, the reviewer will send a letter to the provider. It is important to follow the directions on the letter. This webpage was created to provide information about the process.
The claim-processing edits consists of Retrospective (post-pay) and Prospective (prepay) analysis of claims.
To learn more about the types of audits and timelines:
- Read the Frequently Asked Questions
Retrospective (post-pay)
Clinical Chart Validation (CCV)
Also referred to as a complex review, which requires review of medical records including complex Diagnosis Related Group (DRG).
Retrospective Claims Accuracy (RCA)
Also referred to as data mining. Often related to provider billing issues, such as split bills and excessive units being billed.
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.
