Our Member Services Representatives are unavailable Thursday, November 26, and Friday, November 27, due to the holiday. (Medium)

DRG Validation Coding Audit

Following a DRG Validation Coding Audit (DRG audit), providers must submit a new claim correction request as the Blue Cross Blue Shield of North Dakota (BCBSND) claim system does not allow a claim submission. The provider must respond within 45 days following certified receipt of the DRG audit notification letter.

If the provider agrees with the proposed change, they must submit a claim correction with a copy of the certified letter attached and the recommended corrections within 45 days. If no correction request is received within this
45 day time frame, the claim will be denied.

If the provider disagrees with the DRG auditor’s determination, they may request reconsideration by following the DRG Validation Reconsideration Process. A request for reconsideration must be received by the Provider Audit Department within 45 days of the receipt of the DRG audit certified notification letter.

In fairness to all providers, a claim correction or request for reconsideration received by BCBSND after the 45 day time limit will result in a claim denial and any further opportunity for payment is waived by the provider.

Information about the DRG audit processes can be found in the provider manual published on the BCBSND website.