Reviews on Inpatient DRG Claims for BlueCard® (Out of Area) Medicare AdvantageSM Members

August 9, 2022

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 Montana (BCBSMT) will work with EXL Health (EXL) 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 Montana receiving health care services in Montana.

Medical Records Requests

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

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

For More Information

If you have questions, please contact your BCBSMT Provider Network Representative. For information about BlueCard, see our website under Standards and Requirements.  


EXL Health and EquiClaim, a Change Healthcare Solution, are independent companies that have contracted with BCBSMT to provide medical claim audits for members with coverage through BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding third-party vendors and the products and services offered by them.Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association