CurrentBlue KCPolicy POL-PP-211

Pre- and Post- Service Claim Review

Governs Blue KC's processes for prepayment and post-payment reviews of provider billing and medical records to validate coding, medical necessity, and payment integrity across impacted provider types and commercial lines of business.

Policy Summary

PayerBlue KC

PolicyPre- and Post- Service Claim Review

Policy CodePolicy POL-PP-211

Change TypeVendor updates; added post-pay DRG review; finality of post-pay adjustments

Effective DateDec 1, 2020

Next Review DateDec 1, 2026

Key ActionProvide access to medical records and billing documents upon Blue KC's request; providers will not be reimbursed for review or copy fees.

SourceLink

POLICY UPDATE CHANGES

Updated policy to include post pay DRG review.

Changed DRG partner to Apixio (later Machinify) and updated list of pre-pay vendors.

Policy states that a claim adjusted due to a post pay audit is final and no corrected claim will be accepted.

Updated policy to include information on who post pay vendors are and what resources are used.

POL-PP-211identifier

2026-12-01next review

Zelis, Lyric, Carelon, Machinify, Turning Pointvendors

What We Review

Review focus areas

Criteria and practices subject to review and potential denial/recoupment include but are not limited to:

ALL of the following

Examples of review focus areas
- Improper payment for services (overpayments).
- Payment for services that do not meet professionally recognized standards/levels of care.
- Excessive billed charges or incorrect code selection for services or supplies.
- Billing for items or services that were not provided or should not have been provided based on documentation.
- Unit errors, duplicate charges, and redundant charges.
- Insufficient documentation in the medical record to support billed charges.
- Billing for experimental and investigational items.
- Lack of medical necessity to support billed services or days.
- Services billed that are not covered by the member's benefit plan, Blue KC policies, Medicare policies, or National/Local Coverage Determinations.
- Absence of objective clinical information in the medical record to support the billed condition.
Items not separately payable or included in another charge (bundling/inclusive services).
Also may be reviewed under coding and billing practices to identify improper payments.

Coding References and Tables

CPT coding referenceCPT

CPT code placeholder; specific codes not listed in this policy.

Guidance sources used for coding and billing evaluation

Primary guidance sourcesCenters for Medicare & Medicaid Services (CMS) guidelines, Medicare local and national coverage determinations, and Medicare manuals

Coding and billing referencesAmerican Medical Association Current Procedural Terminology (CPT) guidelines; Healthcare Common Procedure Coding System (HCPCS) rules; ICD-10-CM Official Guidelines for Coding and Reporting

Billing and form standardsUB-04 Data Specifications Manual; National Uniform Billing Guidelines from the National Uniform Billing Committee

Specialty and audit guidanceAmerican Hospital Association Coding Clinic Guidelines; American Association of Medical Audit Specialists National Health Care Billing Audit Guidelines

Other regulatory and clinical sourcesSocial Security Act; FDA guidance; Department of Health and Human Services final rules; national professional medical society guidelines and specialty society publications

Provider Responsibilities and Appeals

Documentation Required

Provider cooperation and cost responsibilities

Blue KC or its authorized representatives will conduct pre- and post-payment reviews of provider billing and medical records. Providers must grant access to medical records and billing documents upon Blue KC's request. Providers will not be reimbursed for review or copy fees and may not balance bill members for reimbursement differences resulting from reviews. Payment may be denied or recouped when required or requested documentation is not submitted for claims identified for audit. When payment is denied or recouped, Blue KC will not be liable for interest or penalties; members are held harmless. Prepayment reviews are used to prevent payment for non-covered or incorrectly coded services. Post-payment (Payment Integrity) reviews confirm claims accurately represent services and detect, prevent, and correct fraud, waste, and abuse.

Prepay vendors include: Zelis; Lyric (primary and secondary clinical editing); secondary clinical editing; high dollar bill review; DRG audits
Post-pay vendors include: Carelon (coding anomaly detection); Machinify (DRG auditor, formerly Apixio); Turning Point
Providers may send a written inquiry when a procedure is denied and, if appropriate, submit a corrected claim for prepayment denials
A claim adjusted due to a post-pay audit is final and no corrected claims will be accepted

Key Definitions

Prepayment review — definition and notes

DefinitionPrepayment review: reviews put in place to prevent payment for non-covered and/or incorrectly coded services prior to payment being made.

PurposeTo validate coding, documentation, and coverage before claims are paid and to prevent incorrect payments or overpayments.

Provider obligationsProviders must grant access to medical records and billing documents upon Blue KC's request; providers will not be reimbursed for review or copy fees and may not balance bill members.

Vendor involvementPrepay vendors include Zelis and Lyric for clinical editing, high dollar bill review, and DRG audits (as applicable).

Appeals/correctionsWhen a procedure is denied via prepayment review, providers may submit a written inquiry and, if appropriate, a corrected claim.

Billing Rule

Dispute and corrected claim rules

When a procedure is denied after prepayment review the provider/facility may submit a written inquiry to request reconsideration and, where appropriate, submit a corrected claim. Corrected claims are allowable for prepayment denials per the Provider Reference Guide. For post-payment audits, any claim adjusted as a result of the audit is final and corrected claims will not be accepted. Providers must identify and work with Blue KC if a member's authorization for release of records conflicts with other laws or regulations. Providers will not be reimbursed for review or copy fees and may not bill members for differences resulting from reviews.

Submit written inquiry for denied procedures (prepayment) and, if appropriate, submit a corrected claim
Corrected claims are not accepted for claims adjusted due to post-pay audits — those adjustments are final
Providers must provide requested documentation or risk denial/recoupment per Provider Reference Guide
Providers may not bill members (no balance billing) for reimbursement differences from audits