Dec. 11, 2025

Beginning Jan. 1, 2026, the dollar amount for high dollar pre-payment reviews (HDPR) will now include claims with an allowed amount of $75,000 or greater for our Group and Individual plans.

The HDPR process is in place to ensure proper payments are applied to high-cost health care claims. The process serves several key objectives like ensuring payment integrity, preventing financial loss, controlling costs, and guarding against fraud, waste and abuse.

What this means to you:

Hospitals will be required to submit an itemized bill for review when the following criteria are met:

• It is an inpatient institutional claim.
• The allowed amount of the claim is $75,000 or greater.
• Any pricing methodology that involves a discount except for:
  • Per-diem
  • Flat-fee case rate
  • DRG rate

When requested, submit the itemized bill through My Insurance Manager℠ using the claims attachment feature. Medical records are not needed and cannot be submitted in lieu of the itemized bill.

How to Identify Group and Individual Members

What Happens During the Process

During the review process, charges on the claim are reduced based on the Payment Integrity findings. These findings are applied to the claim line with the highest charges. The audit threshold is based on the admission date. An outcome of the review, including the report findings, is sent to the hospital's revenue integrity area.

More information about these guidelines can be found in the Inpatient Non-Reimbursable Charge/Unbundling Policy.

If you have any questions about this bulletin, please contact your Provider Relations Consultant.