April 27, 2026
Beginning May 1, 2026, CERIS will conduct post-payment audits of select commercial member claims to ensure accurate coding and appropriate Diagnosis Related Group assignment based on clinical documentation.
CERIS will perform clinical validation to confirm that diagnosis and procedure codes reported on the claim are supported by the medical record and are consistent with the DRG billed and paid.
When a claim is selected for review, you may receive a request for medical records from CERIS. The request will include instructions for submission and applicable timelines.
What happens next? Following the review, providers will receive written notification outlining the findings. If the review determines that the DRG billed is not supported by the submitted documentation, Blue Cross and Blue Shield of Illinois may request a refund or adjustment. Information regarding next steps or reconsideration options will be included in the notification.
If you have questions, please contact your Provider Network Consultant.
CERIS of CorVel Health Corporation 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 they offer.