Skip to main content
Shop Plans Learn more about our coverage options including health, Medicare, dental and vision options for you, your family or your employees. Get Started Individual & Family Medicare Employer Vision Dental International Travel Find Care FAQ Blog Members Stay on top of your health care with helpful member resources. Members Home Medicare Health Dental Vision Find Care Member Knowledge Center Member Forms Medicare Forms Library Make a Payment Federal Employees Student Blue Healthy Blue Providers Access tools, policies and the latest information to help you care for our members. Providers Home Network Participation Networks & Programs Claims, Appeals & Inquiries Prior Authorization Services & CPT codes Prescription Drug Search Policies, Guidelines & Codes Provider News Provider FAQ Contact Us Employers Learn about our coverage options for small and large employers, and access tools and resources for your group. Employers Home Shop Employer Plans Employer Portal Support Member Forms & Resources Find Care Blog Agents Access the tools you need: rate quotes, applications, forms, the latest industry news, marketing materials and more. Agents Home Agent Services Check Eligibility Find Care Member Forms & Resources Medicare Forms Library
Contact Us
Log In
I am ... Please select A member A provider An employer An agent
Log in to Agent Services
Log in to Employer Services Register for Employer Services I'm registered but need portal access
Username Forgot username? Continue to Log In Register for Blue Connect Need help? Learn how to log in.
Log in to Blue e Register for Blue e Log in to Dental Blue
Back
Diagnosis Related Group (DRG) Program Review Effective Date For Medicare Advantage April 26, 2023 Claims & Coding Medical Policy & Clinical Guidelines

In a continuing effort to manage and control health care costs on behalf of our members, Blue Cross NC implemented Diagnosis Related Group (DRG) reviews for our Medicare Advantage members effective January 1, 2023, as indicated in the Blue Cross NC communication linked below. This program was implemented to maintain accuracy in claims payment by ensuring claims are not overpaid or underpaid, in accordance with Blue Cross NC contract terms and polices.  Reviews will be performed on a prepayment and post-payment basis.  Post-payment reviews will apply to claims paid within the last 18 months.  All DRG claims will be subject to review, however not every claim will be selected for review.    

Claim Review Service 

Currently, our vendors perform post-pay DRG validation reviews to confirm correct coding and billing. The DRG payment methodology was created as an effective framework to standardize utilization of services.  Clinical coder reviewers validate the diagnoses and procedures that affect the DRG and ensure diagnostic and procedural information and the beneficiary’s discharge status is consistent with the attending physician’s description and the medical record information.   

The review will apply to claims including but not limited to:  

  • Overpayments  
  • Underpayments
  • Discrepancies in ICD-10 and procedural coding 

Providers may see an increase in communications and requests from vendors that are performing the reviews on behalf of Blue Cross NC.  When requested, providers can submit medical records and schedule in-person reviews (when applicable) without seeking member authorization.  

For information on the DRG reviews for our Fully Insured, and Small Group, Administrative Services Only (ASO), Individual, State Health Plan and IPP/Blue Card Program please refer to previously published communication: Diagnosis Related Group (DRG) Program Review Effective Date for Medicare Advantage (11-01-22).  

These programs will not include the Federal Employee Program market segments at this time.