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.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
Information in other languages: Español 中文 Tiếng Việt 한국어 Français العَرَبِيَّة Hmoob ру́сский Tagalog ગુજરાતી ភាសាខ្មែរ Deutsch हिन्दी ລາວ 日本語
© 2025 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.