CommercialAdministrativeHigh impact
CERIS To Conduct Post-Payment Reviews on Claims
BCBS New Mexico·NM·Reimbursement
Effective date
May 1, 2026
We identified it
Jun 18, 2026
Summary
Starting May 1, 2026, CERIS will conduct post-payment audits on select commercial claims to validate DRG assignments and coding accuracy. Providers may receive medical record requests and could face refund demands if documentation doesn't support the billed DRG.
Action Required
Before May 1, 2026: Ensure all inpatient claims have complete clinical documentation that supports the DRG billed. Review current documentation practices to confirm diagnosis and procedure codes match medical records. Billing team must establish process to respond promptly to CERIS medical record requests with required timelines. Failure to provide adequate documentation may result in refund requests or claim adjustments.