Reviews on Inpatient DRG Claims for BlueCard® (Out of Area) Medicare AdvantageSM Members

The Blue Cross and Blue Shield Association requires all host Blue Cross and Blue Shield (BCBS) Plans to review select inpatient, diagnosis-related group (DRG) claims for any out-of-area Blue Cross Medicare AdvantageSM members. Beginning Oct. 15, 2022, Blue Cross and Blue Shield of New Mexico (BCBSNM) will work with EXL Health (EXL) to complete these reviews. The review will check for compliance with ICD-10 procedure coding system guidelines.

Which claims are affected?

This review affects inpatient DRG claims for services rendered to any hosted BlueCard member with a Medicare Advantage policy. Hosted BlueCard members are members of any BCBS Plan outside New Mexico receiving health care services in New Mexico.

Medical Records Requests

When a claim is selected for review, you may receive a request for medical records from EXL Health.

What happens next? If an error is found in how the claim is coded you’ll receive a letter from EXL that explains the review and the outcome. If the review determines the diagnosis billed is not supported, BCBSNM will request a refund from the provider.  

More Information: If you have any questions, please contact your BCBSNM Provider Network Representative. For information about BlueCard, see our website under Claims & Eligibility.


Checking eligibility and benefits and/or obtaining benefit preauthorization/pre-notification or predetermination of benefits is not a guarantee that benefits will be paid. Payment is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations and exclusions set forth in your patient’s policy certificate and/or benefits booklet and/or summary plan description. Regardless of any benefit determination, the final decision regarding any treatment or service is between you and your patient. If you have any questions, please call the number on the member’s BCBSNM ID card.

EXL Health and EquiClaim, a Change Healthcare Solution, are independent companies that have contracted with BCBSNM to provide medical claim audits for members with coverage through BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding third-party vendors and the products and services offered by them.

Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association