Pre-payment claim review process
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Administrative policy governing BCBSRI's pre-payment claim review process and procedures for participating providers; defines documentation requests, timelines, and appeal rights. Does not apply to Federal Employee Program or fraud/waste/abuse reviews.
No material clinical or coverage changes in this revision.
Scope and Applicability
Policy applicability
Applicability and scope
ALL of the following
- Medical criteria: Not applicable.
- Prior authorization: Not applicable.
- Coverage: Not applicable for this policy (administrative only).
- Does not apply to Federal Employee Program (FEP) or to fraud/waste/abuse reviews or intentional misrepresentation of services.
Outcomes and provider responsibilities
Review outcomes and appeals
ALL of the following
- If records validate claim, claim is approved and processed.
- If pre-payment review results in a denial or reduction, BCBSRI/designee will send a determination letter to the provider that communicates the reason(s) and outlines the provider's opportunity for appeal.
ALL of the following
- Providers must provide records at no cost and grant access or provide copies within sixty (60) calendar days of request to support pre-payment claim review.
ALL of the following
- Provider appeal: Provider may appeal a pre-payment claim review determination to BCBSRI's designee within sixty (60) calendar days from the date of the determination letter by submitting an appeal request and any supporting documentation; appeals may be submitted electronically via a secure portal.
- Only one level of appeal is available; if no appeal is submitted within sixty (60) calendar days, the determination is final.
Coding and Timeliness
| No codes listed |
Provider Responsibilities & Appeal Process
Record production on request — provide records or itemized claim within 60 days
Providers must maintain complete records and, upon BCBSRI/designee request, provide access or copies at no cost within 60 calendar days to support pre-payment claim review. Records must be complete for the date(s) of service and may include physician orders, diagnoses, evaluations, consults, test reports and results, histories, surgical and discharge summaries, consents, care plans, medications, treatments, and documentation of patient response. A provider may be asked to submit a final itemized claim if requested.
- Provide access or copies of records (or grant remote access) to BCBSRI/designee within sixty (60) calendar days of request.
- Ensure records are complete for the requested dates/services and include all supporting documentation (e.g., orders, evaluations, test reports, operative and discharge summaries, consents).
- Submit a final itemized claim when requested by BCBSRI/designee.
Notification of determination — written letter with reasons and appeal information
If a pre-payment review results in denial or reduction, BCBSRI/designee will send a written determination letter to the provider that communicates the reason(s) for the denial/reduction and outlines the provider's opportunity to appeal.
- Determination letter will state reason(s) for denial or reduction.
- Letter will outline the provider's appeal opportunity and relevant next steps.
Appeal submission — file within 60 days with supporting documentation
Providers may appeal a pre-payment claim review determination to BCBSRI's designee within sixty (60) calendar days of the determination letter, submitting any and all additional documentation to support the appeal; appeals may be submitted electronically via a secure portal. Only one level of appeal is available; failure to timely appeal renders the determination final.
- Submit appeal request and supporting documentation to BCBSRI's designee within sixty (60) calendar days from the date of the determination letter.
- Electronic submission via a secure portal is permitted.
- There is only one level of appeal; no further appeal if not timely submitted.
Key Definitions
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