Diagnosis Related Group (DRG) Program and Readmission Reviews

Updates and reminders related to Blue Cross and Blue Shield of North Carolina (Blue Cross NC) post-payment Diagnosis Related Group (DRG) reviews:

• Blue Cross NC has engaged a new vendor, Apixio Technologies, LLC, formerly known as ClaimLogic, to conduct clinical validation reviews (see below for current list of vendors).
• All DRG claims are subject to review.  
• Blue Cross NC has added Medicare Advantage to the impacted market segments.

The process for reviews through Apixio will be different than our other vendors:

Apixio Technologies, LLC will communicate with providers via email. Please review emails from Apixio Technologies, LLC, and follow instructions to access and register on the Apixio provider portal. All letters (medical record requests, findings, reconsideration outcomes, etc.) will be posted on this portal.

Records may be uploaded directly to the portal, OR via Secure File Transfer Protocol (SFTP), OR submit via fax. The portal will also allow providers to electronically sign off on agreement with coding and clinical validation findings, or electronically request a reconsideration review.

Blue Cross NC has communicated previously correct coding requirements i.e. billing for routine supplies, routine services, and upcoding. All reviews will apply to claims paid within the prior 18 months. 

This communication is an update to this communication posted April 14, 2022.

In a continuing effort to manage and control health care costs on behalf of our members, Blue Cross NC will continue the DRG program, implemented December 13, 2021. This was implemented to maintain accuracy in claims payment by ensuring claims are not overpaid or underpaid. All DRG claim charge amounts will be subject to review.  

Claim Review Service Vendors   

Blue Cross NC has contracted with Equian, LLC, Apixio Technologies, LLC, and Claris Health to perform a DRG claim review service on behalf of the Plan.   

Equian, LLC , Apixio Technologies, LLC, and Claris Health, will perform analytics on claims that will include but are not limited to:   

• Overpayments   
• Underpayments   
• Discrepancies in coding (such as upcoding)
• Readmissions

Providers will see electronic communications and requests from the new vendor, Apixio Technologies, LLC, in addition to existing vendors – Claris Health and Equian, LLC regarding their postpaid claims.   

Impacted Market Segments    

The DRG clinical validation 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
• Medicare Advantage

The program will not include Federal Employee Program market segments at this time.