CommercialAdministrativeHigh impact
Upcoming Post-payment Review Process Changes for Group and Individual Plans
BlueCross BlueShield of South Carolina·SC · Emergency Medicine, Critical Care, General Surgery +2 more·Claims
We identified it
Jun 20, 2026
Summary
BlueCross BlueShield of South Carolina will implement a new post-payment review process using Cotiviti Inc. for hospital claims, focusing on short stay admissions, DRGs, and readmissions for group plans with prefixes 61, 62, 64, and 65. Providers will have 45 days to respond to medical record requests and can appeal adverse determinations through a two-level process.
Action Required
Immediately: Hospital billing teams must prepare workflow processes to respond to post-payment review requests from Cotiviti within 45 calendar days. Update staff training on the two-level appeals process (first to Cotiviti, second to BlueCross). Ensure medical records department can quickly retrieve documentation for short stay admissions, DRG cases, and readmissions. Failure to respond timely may result in claim recoupments without appeal opportunity.