Reviewing 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 Texas (BCBSTX) will work with CERiS of CorVel Health Corporation (CERiS) 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 Texas receiving health care services in Texas.

Medical Records Requests

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

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

For More Information

If you have questions, please contact your local BCBSTX Provider Network Office. For information about BlueCard, see our website under Claims & Eligibility.

CERiS of CorVel Health Corporation are independent companies that have contracted with BCBSTX to provide medical claim audits for members with coverage through BCBSTX.

BCBSTX makes no endorsement, representations or warranties regarding third-party vendors and the products and services offered by them.