“Starting in November 2021, Blue Cross Blue Shield of Michigan will begin working with Optum, a data, analytics and consulting group, for enhanced prospective claim editing for services provided to our commercial members. We anticipate that this change will help promote correct coding and support payment accuracy,” (BCBS, 2021). In a recent article from BCBS, they explained to surgical providers that coding will need to be changed starting in November of 2021. However, it is highly recommended to start this process sooner, rather than later. In addition to normal CPT codes for surgical procedures, there will need to be an anatomical code attached to let insurance companies know the part of the body in which the surgery was performed.
BCBS will begin performing enhanced prepayment claim reviews; these reviews will help monitor the usage of codes and if they are being overutilized – in addition, they will prevent unnecessary costs. As a result of these reviews, providers may be asked to provide medical records to back these codes. When asked to submit medical records, there will be complete instructions on each request letter as to how to do that. Forewarning, there is limited allotted time to get the medical records submitted, otherwise providers will see denials on their claims until Optum gets the requested information.
Please follow the links below for more information, and to know which CPT code range needs these enhancements.
“Claim Editing Enhancements Coming to Blue CROSS Commercial Claims.” The Record, www.bcbsm.com/content/dam/microsites/corpcomm/provider/the_record/2021/sep/Record_0921w.shtml.
“Optum to Provide ENHANCED Prospective CLAIM Editing for Blue CROSS Commercial Claims.” The Record, www.bcbsm.com/content/dam/microsites/corpcomm/provider/the_record/2021/aug/Record_0821q.shtml.