Apr. 14, 2022, Update: Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is removing the $100,000 paid dollars threshold for Diagnosis Related Group (DRG) reviews. Effective June 13, 2022, all DRG claims will be subject to review.
In addition, the $100,000 threshold (paid dollars) will still apply to Itemized Bill Review (IBR) reviews for Inter-Plan Program(IPP)/Blue Card claims. For example, a claim with a total billed charge of $250,000 will be reviewed if the total amount paid is $100,000 or greater. If the amount paid is less than $100,000, this will be excluded from review.
Blue Cross NC has communicated previously correct coding requirements ie. billing for routine supplies, routine services, and upcoding. All reviews will apply to claims paid within the last 18 months.
This communication is an update to the original communication posted Jan. 13, 2022.