CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Post-payment audit recovery and adjustments for commercial products

Governs BCBSRI post-payment audit recoveries and provider/institution rights to seek underpayment reimbursement for non-federal commercial products in accordance with Rhode Island General Laws; applies to contracted healthcare providers and institutions delivering services to BCBSRI commercial members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPost-payment audit recovery and adjustments for commercial products

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionProvide BCBSRI or its audit designee, at no cost, electronic copies of complete medical records or remote access for each audited claim within 30 calendar days of request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18 monthsstandard audit/recoupment period

12 monthsMH/SUD audit period

30 daysrecords turnaround

Post‑2015statute alignment

Oct 2022last publication

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Post-payment Audit & Recovery Criteria

Post-payment audit and recovery criteria

Statutory-based timeframes and limitations for post-payment audits, recoveries, and underpayment requests:

ALL of the following

ANY of the following
- BCBSRI shall complete any review, audit or investigation that results in recoupment or set-off no later than 18 months after the claims were initially paid (RIGL §§27-19-56 and 27-20-51).18 months
- For claims submitted by licensed mental health and/or substance use disorder providers participating with the health insurer or health plan, the recoupment period is no later than 12 months after initial payment (statutory exception).12 months
ALL of the following
- Claims submitted fraudulently; claims that are or should have been known by the provider to be a pattern of inappropriate practice; claims related to coordination of benefits; duplicate claims; or claims subject to federal law or regulation that permit review beyond the statutory period may be reviewed beyond the 12/18 month limits.

ALL of the following

Audits or recoupments of institutions or hospitals shall be completed in accordance with the time set forth in the provider's contract; if no contractual time frame exists, the statutory time frames apply (effective after January 1, 2015).

ALL of the following

No provider shall seek reimbursement from a payer for underpayment of a claim later than 18 months from the date the first payment on the claim was made, unless the claim is the subject of an appeal properly submitted pursuant to the payer's claims appeal policies or is subject to continual claims submission.18 months
If a negotiated provider contract specifies a different time frame for underpayment requests or appeals, the contractual time frame governs.

ALL of the following

Upon request, providers must furnish BCBSRI or its audit designee, at no cost, electronic copies of complete medical records or provide remote access for each audited claim within 30 calendar days; failure to provide access may result in recovery of the full claim amount.30 days
BCBSRI may elect to use extrapolation based on generally accepted statistical sampling methods limited to the defined audit population/product area when conducting recoveries.

ALL of the following

Time frames for appeals of denied claims are governed by the provider's contract and are not altered by this policy; appeals must be submitted within contractual appeal time frames to toll the statutory underpayment deadline.

Coding and Audit Lookback Periods

Codingmixed

No coding rules applicable (Not applicable)

Audit lookback periods — statutory timeframes

Standard audit/recoupment period18 months after claims were initially paid for most providers

Mental health/substance use disorder providers12 months after claims were initially paid

Institutions/hospitalsFollow contract timeframes or, if none, statutory timeframes (18 months; 12 months for behavioral health)

Provider Obligations and Audit Procedures

Documentation Required

Provision of Records for Audit

Provide BCBSRI or its audit designee, at no cost, an electronic copy of the complete medical record or grant remote access to obtain records for each audited claim within 30 calendar days of the request; failure to provide access may result in recovery of the full claim amount.

Electronic copy of complete medical record or remote access required
Provider bears no cost for furnishing records
30 calendar day deadline from BCBSRI request
Failure to comply may lead to recovery of full claim amount

Denial Risk

Extrapolation and Sampling

BCBSRI may elect to use extrapolation based on generally accepted statistical sampling principles; any extrapolation will be limited to the defined audit population and will not be carried over to other claim areas or BCBSRI products.

Key Definitions

Healthcare provider — definition

Definition (general)An individual clinician (in independent practice or in a group) who provides healthcare services, and any healthcare facility as defined in RIGL 27-20-1

Includes mental health/substance abuse providersIncludes mental health and/or substance abuse treatment physicians or other licensed practitioners identified as having primary responsibility for care

ScopeApplies to contracted healthcare providers and institutions delivering services to BCBSRI commercial members (non-federal products)

Defined audit population

MeaningArea within a specific BCBSRI product (for example, emergency department claims for the BCBSRI commercial product)

Extrapolation limitation