We’re updating review threshold for high-dollar prepayments

Since 2017, Blue Cross Blue Shield of Michigan and Blue Care Network have been partnering with Equian, an independent company, to review certain types of high-cost inpatient claims. This review helps us detect and resolve errors before payment to ensure that all claims will be paid right the first time.

As we previously communicated, Blue Cross and BCN intended to review high-cost claims greater than $25,000. But since beginning the review process in May 2017, we’ve only examined claims greater than $100,000. After five years of reviews at this higher amount, Blue Cross and BCN have decided to lower the review threshold.

Effective Jan. 1, 2023, high-cost claims greater than $75,000 are now eligible for high-dollar prepayment review by Blue Cross and BCN.

This change only affects the review threshold. It doesn’t affect any other aspect of the current high-dollar prepayment review process, including claim payments and reconsideration time frames.

For more information:

• A detailed look at the process is available in the Blue Cross provider manual under the “High-cost claims review process” section.
• You can also read the previously published articles in the April 2017 issue and August 2017 issue of The Record, and the March-April 2017 issue of Hospital and Physician Update.

If you have any questions, contact your provider consultant.