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) is monitoring and auditing High-Cost Drug errors (HCD), Cross Benefit Billing Errors (CBBE) and Same Benefit Billing Errors (SBBE). These three programs maintain accuracy in claims payment by ensuring claims are not overpaid or underpaid.

The Rawlings Company performs HCD, CBBE and SBBE claim review services on behalf of the Plan and analytics that include but are not limited to: 

• Overpayments
• Discrepancies in coding (such as upcoding)

Providers may see an increase in communications and requests from The Rawlings Company regarding their postpaid claims.

Program Descriptions

• The Cross Benefit billing error investigation identifies drug claims that were billed under both the patient’s medical benefit (by the administering provider) and retail pharmacy benefit (typically by the specialty pharmacy supplying the drug) and relate to the same medical date of service.
• The Same Benefit billing error investigation identifies drug claims that were billed to the patient’s medical benefit by more than one provider for the same medication and treatment on the same medical claims processing platform.
• The High-Cost Drug billing error investigation examines a variety of billing anomalies in medical drug claims to identify overpayments relating to billed units, charge amount and payment amount.

Impacted Market Segments 

The HCD, CBBE and SBBE programs are applicable to the following market segments:

• Fully Insured Large and Small Groups
• Individual
• Administrative Services Only (ASO)
• Medicare Advantage

These programs will not include the State Health Plan, Federal Employee Program^® or IPP / Blue Card Program market segments at this time. 

This update is for information purposes only.