Threshold Amount for Claims Review for Blue Cross Community CentennialSM Members
In furtherance of payment integrity and adherence to claims payment policy, Blue Cross and Blue Shield of New Mexico (BCBSNM) performs post-service, pre-payment reviews of claims with potential payments greater than a certain amount.
By this letter, BCBSNM is informing you that for dates of service (outpatient / professional) and admission (inpatient) on and after August 31, 2020, the threshold amount for such reviews of claims for services furnished to Blue Cross Community CentennialSM members will be $100,000.00. This process update will impact the following claims:
- Inpatient claims where the facility has a DRG contract with a stop-loss provision and the potential payment is $100,000.00 or greater; and
- All outpatient and professional claims with a potential payment of $100,000.00 or greater.
For impacted claims, providers must submit complete medical records, itemized bills, and invoices for implants (if applicable), along with the claim. If requisite documents are not submitted with the claim, processing of the claim will be delayed until the documents are received. Medical records, itemized bills, and invoices can be submitted electronically via Availity or through Epic.
If you have questions about this process update, please contact your assigned provider representative . You may also want to explore the resources available under the Providers tab at bcbsnm.com, which includes medical policies, medical records documentation standards, clinical payment and coding policies, and much more.
Blue Cross Community Centennial Claims & Customer Service
Blue Cross and Blue Shield of New Mexico
Such services are funded in part with the State of New Mexico.