As part of our ongoing efforts to manage health care costs and ensure accurate payments for our members, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) implemented a post-payment Diagnosis Related Group (DRG) review program on December 13, 2021. To further streamline this process, Blue Cross NC has contracted with Machinify, LLC to shift these reviews to pre-payment with an effective date of November 26, 2025.

These pre-payment reviews will help ensure correct coding and accurate payment of claims – improving overall claims experience as well as operational efficiencies. By requesting and reviewing records prior to payment, we can streamline the process and reduce the need for post-payment recoupments.

As part of the pre-payment review process, DRG evaluations will be based on medical records. Please note the following:

• DRG claims identified as requiring additional medical records will be selected, and Machinify, LLC will request the necessary records directly from providers.

To help onboard you to this new process, Machinify, LLC will communicate directly with providers via email. We encourage you to monitor for these emails and follow the instructions to access and register on their provider portal. Machinify will also offer additional training and educational resources to help providers navigate their provider portal. 

All letters (medical record requests, review findings, reconsideration outcomes etc.) will be posted in the Machinify provider portal for easy access. 

When medical records are requested, providers will submit them directly to Machinify, LLC using whichever method works best:

• Upload directly to their provider portal
• Use Secure File Transfer Protocol (SFTP)
• Submit via fax

The Machinify provider portal also allows providers to:

• Electronically sign off on agreement with coding and clinical validation findings
• Electronically submit reconsideration requests directly to Machinify, LLC

Impacted market segments   

The DRG clinical validation reviews will be conducted on pre-paid claims in the following market segments:   

• Fully Insured Large and Small Groups   
• Administrative Services Only (ASO)   
• Individual
• IPP / Blue Card Program
• Medicare Advantage
• The program will not include Federal Employee Program market segments at this time.

Reminder: post-pay claim review service vendors  

Contracted vendors will continue to perform post-payment selections and reviews on behalf of Blue Cross NC on inpatient facility claims as appropriate. This includes, but is not limited to:  

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