CurrentBlue KCPolicy POL-PP-211

Pre- and Post- Service Claim Review

Governs Blue KC's process for conducting prepayment and post-payment reviews of provider claims, documentation access requirements, recoupment/denial practices, and vendor use; applies to providers and facilities billing Blue KC members.

Policy Summary

PayerBlue KC

PolicyPre- and Post- Service Claim Review

Policy CodePolicy POL-PP-211

Change TypeVendor updates and finality of post-pay adjustments

Effective DateDec 1, 2020

Next Review DateDec 1, 2026

Key ActionProviders must grant access to medical records and billing documents upon Blue KC's request for pre- and post-payment reviews.

SourceLink

POLICY UPDATE CHANGES

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

Updated list of pre-pay vendors to include Zelis and Lyric and identified specific prepay activities.

Updated DRG partner/vendor names over time (changed to Machinify/formerly Apixio; previously Cotiviti).

Providers will not be reimbursed for review or copy fees and may not balance-bill members for reimbursement differences resulting from reviews.

vendorsprepay & postpay vendors named

16external resources referenced

10problematic billing examples

multipleimpacted provider types

Audit Coverage and Outcomes

Audit coverage criteria and outcomes

Covered when documentation is provided as requested; Blue KC may deny or recoup payment and pursue audit outcomes described below when documentation or medical necessity is not supported.

Blue KC or its authorized representatives will conduct pre- and post-payment reviews of providers' billing and records for services provided to Blue KC members; providers must grant access to medical records and billing documents upon request.

Providers will not be reimbursed for review or copy fees and may not bill members for reimbursement differences (balance billing); Blue KC will not be liable for interest or penalties when payment is denied or recouped and members are held harmless for such denials.

Payment may be denied or recouped when the facility or professional provider fails to submit required or requested documentation for claims identified for prepayment or post-payment audit; when a procedure is denied after prepay review the provider may send a written inquiry and, if appropriate, submit a corrected claim; however, a claim adjusted due to a post-pay audit is final and corrected claims will not be accepted.

Audit focus areas

Policy Summary

PayerBlue KC

PolicyPre- and Post- Service Claim Review

Policy CodePolicy POL-PP-211

Change TypeVendor updates and finality of post-pay adjustments

Effective DateDec 1, 2020

Next Review DateDec 1, 2026

Key ActionProviders must grant access to medical records and billing documents upon Blue KC's request for pre- and post-payment reviews.

SourceLink

On This Page

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Provider Responsibilities and Dispute Process

Documentation Required

Medical record and documentation access; fees and balance billing

Blue KC and its authorized representatives will conduct pre- and post-payment reviews of providers' billing and medical records for services provided to Blue KC members. Providers must grant access to medical records and billing documentation upon request for these reviews. Providers will not be reimbursed for any review or copy fees related to claim reviews, and may not balance-bill members for any reimbursement differences that result from the review. If a provider fails to submit required or requested documentation for claims identified for prepayment or post-payment audit, payment may be denied or recouped as outlined in the Provider Reference Guide. When payment is denied or recouped, Blue KC will not be liable for interest or penalties, and members will be held harmless. Plan members have authorized Blue KC to obtain necessary medical records or other information per the member Evidence(s) of Coverage; if a member release conflicts with law or regulation, the Provider must identify the conflict and work with Blue KC to resolve it.

Prepayment reviews prevent payment for non-covered or incorrectly coded services prior to payment.
Prepay vendors include: Zelis; Lyric (primary and secondary clinical editing); and vendors performing secondary clinical editing, high dollar bill review, and DRG audits.
Post-payment (Payment Integrity) reviews confirm claims accurately represent services and detect/correct fraud, waste, and abuse.
Post-pay vendors include: Carelon (coding anomaly detection); Machinify (DRG auditor, formerly Apixio); Turning Point.

Billing Rule

Dispute and corrected claim process

Providers whose claims are denied through prepayment reviews may submit a written inquiry for Blue KC to review the claim. If appropriate after review, the provider may submit a corrected claim. For claims adjusted as the result of a post-pay audit, the adjustment is final and corrected claims will not be accepted. Providers must follow the written inquiry and corrected-claim processes described in the Provider Reference Guide. When an audit results in denial or recoupment, limits described in audit communications and the Provider Reference Guide apply and the member remains held harmless.

Submit a written inquiry when disputing a prepayment denial; follow Provider Reference Guide procedures for corrected claims.
Corrected claims are permitted for prepayment-reviewed denials when Blue KC determines it appropriate.
Claims adjusted due to a post-pay audit are final; corrected claims will not be accepted for post-pay adjustments.
Providers must supply any requested documentation to support dispute or corrected claim; failure to provide documentation may result in denial or recoupment.

Prepayment and Post-payment Reviews — Definitions

Prepayment reviews — definition and vendor activities

DefinitionPrepayment reviews are audits performed prior to payment to prevent payment for non-covered and/or incorrectly coded services.

Common activities/examplesSecondary clinical editing; high dollar bill review; DRG (diagnosis related group) audits.

Typical vendors (examples)Zelis; Lyric (primary and secondary clinical editing).

Provider requirementsProviders must grant access to medical records and billing documents upon Blue KC's request for pre- and post-payment reviews.

Billing/fee rulesProviders will not be reimbursed for review or copy fees and may not balance-bill members for reimbursement differences resulting from reviews.

Post-payment (Payment Integrity) reviews — definition and vendor examples

DefinitionPost-payment (Payment Integrity) reviews are audits performed after payment to confirm claim accuracy and to detect, prevent, and correct fraud, waste, and abuse.

Common activities/examplesDRG auditing; coding anomaly detection; post-service claim validation.

Typical vendors (examples)Carelon (coding anomaly detection); Machinify (DRG auditor, formerly Apixio); Turning Point.

Outcome finalityA claim adjusted due to a post-pay audit is final; no corrected claims will be accepted.

Related provider impactPayment may be recouped or denied when required documentation is not provided; members are held harmless.

OpenPayer

Pre- and Post- Service Claim Review

Audit Coverage and Outcomes

Referenced Coding Systems

Provider Responsibilities and Dispute Process

Prepayment and Post-payment Reviews — Definitions