Medicare Advantage non-compliance audits to begin Oct. 1, 2018

Blue Cross Blue Shield of Michigan is changing our audit policy on pursuing the submission of Additional Documentation Requests (also known as ADRs). Beginning Oct. 1, 2018, Blue Cross will implement existing Medicare policy to ensure program compliance for letters requesting medical records. Previously, we did not pursue remedies on non-responses to these letters.

Providers who do not respond to the request in the allotted time frame or by the extension time frame can have their entire claim or service denied as not reasonable or necessary. Providers will be notified that Blue Cross has issued a non-compliance denial for a claim or service and the claim will be recovered from future payments.

If Blue Cross receives the requested ADR after a denial has been issued, but within 30 calendar days after the last denial date, we will re-open the claim and make a medical record determination. In these situations, you can follow the two-step appeal process as outlined in the Medicare Plus Blue^SM PPO manual. If the determination is overturned after the record review, we will repay the amount recovered. Otherwise, the recovery will stand.

If you have questions, check your provider manual.