BCBSRI is committed to continuously improving payment integrity to prevent overpayments due to waste or abuse. Effective 20 de julio24, BCBSRI began performing additional prepayment claim reviews using Optum’s Comprehensive Payment Integrity (CPI) tool, which ensures that claims are processed and paid accurately. As a result of these reviews, providers may be asked for medical records and billing documents that support the charges billed. After medical records are reviewed, the claim is processed to be paid if the documentation supports the claim as billed.

BCBSRI uses widely acknowledged national guidelines for billing practices and supports the concept of uniform billing for all payers. Prepayment claim reviews will look for overutilization of services or other practices that directly or indirectly result in unnecessary costs. Documentation to support the diagnosis and services/supplies billed must be included in the medical record.

If requested, providers will receive detailed instructions about how to submit the documentation. If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to appeal results of reviews. 

For additional information please review the payment policy here.