March 9, 2026

BlueCross BlueShield of South Carolina will soon use Cotiviti Inc. to conduct post-payment reviews of select hospital claims for its group and individual plans. This includes group number prefixes 61, 62, 64 and 65.

A definitive implementation date will be communicated once finalized. At this time, we are providing advance notice so you can prepare for this upcoming change.

Scope of Review

This process will apply to hospital claims for:

• Short stay admissions
• Diagnosis-related groups (DRGs)
• Readmissions

The purpose of this review is to ensure accurate and appropriate billing in accordance with applicable policies and guidelines.

What to Expect

If a claim is selected for review, providers will receive a medical records request letter from Cotiviti. Providers will have 45 calendar days from the date of the request to submit the requested medical records for review.

Once records are received:

• Cotiviti will conduct clinical and coding review.
• A determination will be made.
• If an adjustment or refund is warranted, notification will include details regarding the recoupment.

Appeals Process

If you disagree with the determination, there are two levels of appeal:

First-level Appeal

• Must be submitted directly to Cotiviti.
• Cotiviti will review the appeal and issue a decision.

Second-level Appeal

• If the first-level appeal is upheld, providers may submit a second-level appeal to BlueCross.
• BlueCross will review all submitted documentation and make a final decision.
• Providers will be notified of the outcome, whether the decision is upheld or overturned.

We appreciate your continued partnership and commitment to providing quality care to our members. If you have any questions, feel free to contact your Provider Relations Consultant.