Follow these guidelines for audits of catastrophic cases

Please use the following information as a guide for what to expect and do for your hospital’s next utilization review of catastrophic cases.

Blue Cross Blue Shield of Michigan sends appointment letters to the hospital at least 30 days in advance of the audit, listing the cases to be audited and the items required to conduct the audit.

Audits of catastrophic cases require:

• The complete medical record
• Progress notes
• Medication administration sheets organized by date order

The file needs to include emergency room records, outpatient procedures, the utilization review worksheets and a copy of the most current itemized bill.

Blue Cross will only consider adjustments, late charge claims reported with frequency code 5 or replacement claims reported with frequency code 7 if billed to the catastrophic claim 30 or more days before the audit. This allows Blue Cross to finalize the late charge or replacement claim adjustments and post the new claim information to our financial systems before the scheduled audit.

Late charge or replacement adjustment claims reported less than 30 days of the scheduled audit won’t be considered in the catastrophic outlier audit.

If the audit is conducted at your site and you have electronic medical records, please provide:

• One computer for each auditor
• An individual access or login permission for each auditor

The auditor will need someone from your staff to help him or her access and navigate your electronic medical record.

Each auditor will also need an electrical outlet for his or her Blue Cross computer and a telephone in the designated audit room.

If the audit is conducted at our offices and you grant us web access, we require an individual login for each auditor and a contact person who can help access the electronic record.

The Blue Cross auditor usually makes a courtesy call to the hospital contact person before beginning the audit to answer questions that may occur during the preparation.

We’ll provide you with daily deletion sheets during the audit so you have the opportunity to gather additional supporting documentation. While onsite, the auditor will identify the itemized bills to be mailed to Blue Cross.

We’ll need the name, title and email address of the person who should receive the reporting letter. The hospital staff has the responsibility to share audit findings with other individuals or departments in the hospital.

After you receive the reporting letter, you have the opportunity to provide clarification or missing documentation during the appeal process. Hospitals are allowed 50 calendar days from receipt of the audit reporting letter to submit a written request for internal review.

Need more information?

For more information on reviews of catastrophic cases, see your online provider manual. Refer to the chapter titled Catastrophic case review – Peer Groups 1-4 (Inpatient hospital facility).