New Diagnosis Related Group (DRG) and Itemized Bill Review (IBR) Programs Starting May 2021

Dec. 10, 2021 Update: This communication has been reposted to provide an update on the effective date for the DRG program, which has moved from June 5, 2021, to December 13, 2021. The communication was originally posted on March 1, 2021. 

In a continuing effort to manage and control health care costs on behalf of our members and the health care community, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will begin implementing a new Itemized Bill Review (IBR) program effective May 10, 2021, and a new Diagnosis Related Group (DRG) program effective December 13, 2021. These two new programs are being implemented to maintain accuracy in claims payment by ensuring claims are not overpaid or underpaid. DRG and IBR claim charge amounts over the $100K threshold will be subject to review. 

Claim Review Service Vendors 

Blue Cross NC has contracted with Claris Health, Change Healthcare (CHC) and Equian, LLC, to perform a DRG claim review service on behalf of the Plan. 

Claris Health, CHC and Equian, LLC, will perform analytics on claims that will include but are not limited to: 

• Overpayments 
• Underpayments 
• Discrepancies in coding (such as upcoding) 

Once the IBR and DRG programs are implemented, providers may see an increase in communications and requests from Claris Health, CHC and Equian, LLC in regard to their postpaid claims. 

Impacted Market Segments 

The DRG and IBR data analytical reviews will be conducted on postpaid claims in the following market segments: 

• Fully Insured Large and Small Groups 
• Administrative Services Only (ASO) 
• Individual 
• IPP/Blue Card Program (will now include postpaid claims) 

These programs will not include State Health Plan, Medicare Advantage and Federal Employee Program market segments at this time. 

This update is for information purposes only. No further action is needed.