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Payment Integrity Program

BCBSND is enhancing 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.

A two-level strategy for accuracy

The Payment Integrity Program implements a robust Retrospective (post-pay) and Prospective (prepay) analysis of claims.

Retrospective (post-pay)

The following retrospective audits will begin in Q3 of 2022 and will be phased in through the end of Q4 2022. To learn more about the Payment Integrity Program, types of audits and timelines, you can view our Education on Demand (EOD) presentations.

  • Clinical Chart Validation (CCV): This is an analysis-driven audit requiring review of medical records and includes complex DRG (diagnosis, revenue codes and procedure codes) review (beyond just coding and documentation).
  • COB Validation (COB): Identifies when another carrier or entity should be responsible for paying on a claim.
  • Retrospective Claims Accuracy (RCA): Most often these will be provider billing issues, such as split bills and excessive units being billed.

Prospective (pre-pay)

Starting Q4 of 2022, all claims will go through two different Prospective reviews.

  • 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. These claims are reviewed by qualified clinical professionals that determine if these complex claims have been coded appropriately.

Claims will be reviewed on the following concepts:

  • Duplicate, including professional and technical components
  • Modifier usage
  • NCCI
  • Daily and annual unit limits
  • Global services

Providers will receive results of these reviews on their Electronic Remittance Advice (ERA). If a provider disagrees with a payment determination, request a Reconsideration using the Appeal form

Enhanced Payment Integrity Program Frequently Asked Questions (FAQ)