High Dollar Pre-payment Review (HDPR): CARC 216, RARC N183

High Dollar Pre-payment Review (HDPR): CARC 216, RARC N183

On Jan. 1, 2021, the dollar amount for high dollar pre-payment reviews (HDPR) was reduced to $100,000.00 and requires itemized bills for the review to be completed.  Submit itemized bills, when requested, via My Insurance Manager℠ (MIM) using the claims attachment feature.  MIM can be accessed through www.BlueChoiceSC.com.

Note: If medical records are needed, a separate request will be sent to include instructions on how to submit.  Please refrain from submitting unwarranted medical records.

What this means to you:

Hospitals are required to submit an itemized bill in order to process claims when the following criteria are met:

  • Inpatient institutional (acute care) claims; and
  • Claims with an allowed amount of $100,000 or greater; and
  • Any pricing methodologies except for the following pricing models that do not incorporate individual charges due to global pricing:
    • Per-diem
    • Flat-fee case rate
    • DRG rate (those in which a portion of the claim is charge-sensitive)

During the review process, charges on the claim are reduced based on the Corporate Audit findings of the claim line with the highest charges.  This audit threshold is based on the admission date.  A claim line with the revenue code 0249 is added to the claim and is denied with the associated CARC and RARC which state:

A review of the itemized bill has identified charges as unbundled/non-reimbursable based on our internal high dollar review process.

Note: This is based on the application of the BlueCross BlueShield of South Carolina Corporate Policy, Inpatient Non-Reimbursable Charge/Unbundling Policy.  To read this policy in its entirety, click here.

Records will be able to be balanced using the letter and audit sheets sent by Corporate Audit, as well as the remittance advice.

If you have any questions regarding this bulletin, please reach out to Provider Education using the Provider Education Contact Form located on www.BlueChoiceSC.com.