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

July 13, 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 Illinois (BCBSIL) 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 Illinois receiving health care services in Illinois.

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, BCBSIL will request a refund from the provider.   

For More Information 
If you have questions, please contact your assigned BCBSIL Provider Network Consultant. Look here for information about BlueCard and to view our BlueCard Program Provider Manual.


EXL Health and EquiClaim, a Change Healthcare Solution, are independent companies that have contracted with BCBSIL to provide medical claim audits for members with coverage through BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding third-party vendors and the products and services offered by them.