New DRG Dispute time frames

Effective immediately, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) providers will have a 45-day period available to them for vendor conducted post-pay DRG clinical coding reviews. This is a change from the current 30-day period to dispute findings. Providers will begin to see letters reflecting this change from vendors on the following effective dates:

Apixio: 12/04/2024 or sooner

Equian:  11/11/2024

This is in keeping with other dispute periods issued for other coding reviews.

For additional information regarding previously posted communication about DRG Program and Readmission Reviews visit this provider news.

Impacted Market Segments

The DRG clinical validation reviews will be conducted on postpaid claims in the following market segments:

• Fully Insured Large and Small Groups
• Administrative Services Only (ASO)
• Individual
• State Health Plan (As of January 2022)
• IPP / Blue Card Program
• Medicare Advantage & Experience Health

The program will not include Federal Employee Program market segments at this time.