Payment Integrity Program

The enhanced BCBSND Payment Integrity Program expands the current program capabilities and includes several additional reviews during and after the claims processing cycle to safeguard members’ health care dollars. Examples include:

• Duplicate claims checking
• Coordination of benefits, subrogation and credit balance recoveries
• Enhanced fraud, waste and abuse programs supported by new data analysis capabilities
• High-dollar case reviews and inpatient (DRG) claim coding audits
• Enhanced coding edits and validations to meet national standards

• Commercial (Fully-Insured and Self-Funded)
• Medicaid Expansion
• FEP

A few Blues plans started implementing this program effective July 1, 2021. Through our BlueCard system, BCBSND customers may see claims enhancements and program results with services and associated claims after July 1, 2021.

BCBSND implemented through a phased approach with Retrospective effective August 2022 and Prospective December of 2022.

The Blues system recently conducted a market assessment of the payment integrity landscape within plans across the country and found that there was an opportunity to create greater consistency in claims processing payments.

We are adding a deeper level of analytics beyond our core claims processing. Health care claims will continue to be processed automatically through our in-house core claims processing cycle, which remains strong with a thorough system of checks and balances.

Our new enhanced level of analysis is being done through our partnership with Cotiviti.

When submitting a claim correction that impacts two claims, such as adding a modifier on one claim due to a reduction or denial on another claim, use the process outline in the applicable BCBSND provider manual(s) under section “Tip: Submitting Claim Corrections Impacting Two Claims” for further details.

BCBSND Provider Manual

Medicaid Expansion Provider Manual

Providers can learn more about the Payment Integrity Program through updates via HealthCare News.

If you have any specific questions to the program, please contact BCBSND Provider Services at 800-368-2312. If you have questions on medical records, please contact Cotiviti at 833-931-1789.

When to Contact Cotiviti
Providers and Billing Agents should contact Cotiviti on any of the following items:

• Request duplicate letters
• Discuss audit findings/rationale
• Reconsideration questions
• Update provider contact information 

Who to Call

*Monday thru Friday from 7:00am to 4:00 pm CST/CDT

Information to Provide
Cotiviti has a voicemail box for all incoming calls. Providers and Billing Agents should leave a detailed message and include the information:

• Your name
• Call back number and extension, if applicable
• Patient account number and/or reference number
• Cotiviti ID, Voucher Number or Request ID, if applicable
• Detailed question or request

Cotiviti responds to all calls within 24 hours.

Please contact BCBSND Provider Service at 800-368-2312 or BCBSND Medicaid Expansion at 833-777-5779. Cotiviti should not be contacted for any prospective questions.