Medicare Provider Notification for Prepay Reviews by CERiS (Healthy Blue + MedicareSM HMO-DSNP)

Please note, this communication applies to Healthy Blue + MedicareSM (HMO-DSNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

Blue Cross NC, in conjunction with designee, CERiS, will begin performing line item facility claim reviews. CERiS’ professional review process identifies errors, unrelated charges, and non-separately billable charges on facility claims for inpatient services, on a prepayment basis. 

Facility claims consist of charges for routine services and ancillary services. If a provider’s contract does not specify which items, supplies, and services are classified as routine or ancillary, CERIS uses payer policy, CMS regulations, and commercially reasonable industry practices to identify routine service and supply charges that are customarily included in the primary service charge. This is generally the room and board fee for inpatient claims and the procedure fee or operating room time fee for outpatient claims. In order to conduct such reviews, Blue Cross NC or CERiS may request documentation, most commonly in the form of the itemized bill. Once contacted, please submit requested information within seven calendar days. Blue Cross NC may accept additional documentation from the provider such as: other documents substantiating the treatment or health service or delivery of supplies; provider’s established internal policies; or business practices justifying the healthcare service or supply.

Note: CERiS is an independent company providing claim service review for Healthy Blue + Medicare providers on behalf of Blue Cross and Blue Shield of North Carolina.

For more information, go to the Healthy Blue Medicare page.

NCBCBS-CR-009528-22 October 2022