New prepayment DRG review process goes into effect Dec. 1

In 2023, Blue Cross Blue Shield of Michigan took the proposed prepayment diagnosis-related group review program through the Contract Administration Process and the program was put on hold. After further review, Blue Cross will implement the program for inpatient facility claims on Dec. 1, 2024. This program aims to streamline payment processes for health care providers and payers and will be conducted by Optum.

What you need to know

• This is a coding review, not a medical necessity review. The focus is on ensuring accurate coding and appropriate DRG assignment.
• Medical records will be requested by mail; however, the records may be submitted through the Optum provider portal.
• Time frames for submission and review:
• Medical record submission:
• Facilities will have 60 business days from of the mailed request to submit medical records. If the records aren’t received within 60 business days, the claim will deny.
• Initial review:
• Optum will review the submitted medical records within 14 business days from the date of receipt.
• Reconsideration review:
• Optum will review the submitted medical records within 30 business days from the date of receipt.
• Appeals process:
• Providers will have 180 business days from the date of the prepayment DRG determination notification to submit a level 1 reconsideration.
• If the reconsideration determination is upheld, providers may request a level 2 appeal within 60 business days. This is a peer-to-peer review conducted by an independent, impartial external review organization.
• If the peer-to-peer review upholds the initial decision, the facility will cover the cost of the review.
• If the peer-to-peer review overturns the initial decision, Blue Cross will cover the cost of the review.
• Claim processing:
• If the billed DRG is supported, the claim will be processed as submitted.
• If the billed DRG isn’t supported, the claim will be processed using the revised DRG. The facility will receive a detailed findings letter explaining the rationale for the adjusted DRG.

Submitting medical records

Optum offers multiple methods for secure and efficient document submission:

• Secure internet upload:
1. Click here.**
2. Enter the required information (Authorization Code, Record Bar Code, First Date of Service) found on the bar-coded cover sheet that will be enclosed with the medical records request.
3. Upload documents in .jpg, .pdf or .tif format (unsecured .pdf only).
• Hard copy:
• Mail: Blue Cross Blue Shield of Michigan
  P.O. Box 51055
  Philadelphia, PA 19115
• Delivery services: Blue Cross Blue Shield of Michigan
  458 Pike Road
  Huntingdon Valley, PA 19006

• CD/DVD:
• Follow detailed instructions provided by Optum for file naming, format and password protection.

New Optum payment integrity portal

Optum has a new online provider portal to streamline the prepayment review process. This portal enables:

• Secure management of Optum medical record requests.
• Self-registration for providers using Optum One HealthCare ID (OHID).
• Easy document uploading and tracking.

How to register for the Optum portal

Detailed instructions for self-registration and portal usage are available in the “Optum offers new online portal to upload medical records on behalf of Blue Cross” article in this issue of The Record.

Optum is an independent company that manages medical record requests for Blue Cross Blue Shield of Michigan.