Update: Diagnosis Related Group (DRG) Program Review Threshold

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.

In a continuing effort to manage and control health care costs on behalf of our members, Blue Cross NC will begin implementing a new IBR program effective January 24, 2022, in addition to the new 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. IBR claim charge amounts over the $100K paid dollars threshold and all DRG claim charge amounts 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 paid dollars. 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.