Jan. 13, 2022 Update: Blue Cross and Blue Shield of North Carolina (Blue Cross NC) wants to make providers aware of an update to a previously communicated article posted March 1, 2021, regarding the IBR program for commercial business. The IBR program that was initially scheduled to begin May 10, 2021, is now delayed until January 24, 2022.  

In a continuing effort to manage and control health care costs on behalf of our members, Blue Cross NC will begin implementing a new Itemized Bill Review (IBR) program effective January 24, 2022, in addition to the new Diagnosis Related Group (DRG) program, that was 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 regarding 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   
• State Health Plan (As of January 2022) 
• IPP/Blue Card Program 
  • Currently the threshold for IPP is $100,000. Postpaid claims will now be included in the IBR review. 

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