BCBSRI is committed to continuously improving its overall payment integrity solutions to prevent overpayments due to waste or abuse. Effective July 2024, BCBSRI will begin performing additional prepayment claim reviews utilizing Optum’s Comprehensive Payment Integrity (CPI) tool, which ensures that claims process and pay accurately. As a result of these prepayment claim 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 pay, if the documentation supports the claim as billed.

BCBSRI utilizes 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 present 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.