Provider notification — prepay itemization bill review

Empire BlueCross BlueShield (Empire), in conjunction with designee, CERiS,* will begin performing line item facility claim reviews. CERiS’ professional review process identifies errors, unrelated charges, and non-separately billable charges on facility claims for inpatient services, on a prepayment basis.  

Claims should be billed and appropriately coded according to Empire policies along with industry standard coding guidelines for the applicable bill type (including but not limited to UB Editor, AMA, CPT, CPT Assistant, HCPCS, DRG guidelines, CMS’ National Correct Coding Initiative (CCI) Policy Manual, CCI table edits and other CMS guidelines).

CERiS may request documentation, such as an itemized bill, to conduct the professional review. Once contacted, please submit requested information within seven calendar days. Empire and CERiS may accept additional documentation from the provider such as other documents substantiating the treatment or health service or delivery of supplies; provider’s established internal policies; or business practices justifying the healthcare service or supply.