New Audit Requirements for Million-Dollar Claims

Effective July 1, 2026, the Blue Cross Blue Shield Association (BCBSA) is mandating that all Blue Plans, including Highmark, audit claims allowing $1 million or more to ensure billing accuracy.

Important: Highmark’s policy requiring itemized bills for high-dollar claims remains in effect. The new BCBSA mandate is an additional requirement for claims of  $1 million or more.

How the Audit Mandate Works

Plans — both Host and Home — will be required to perform the following activities prepay:

1. Host Plan Responsibilities

• Itemized bill review
• Diagnosis Related Group (DRG) review
• Claim data and financial accuracy, including:
  • Pricing review
  • Plan payment policy review
  • Provider contract review
  • Line by line review
  • Never event review
  • HAC (Hospital-Acquired Conditions) review
• Core clinical editing
• Advanced editing/secondary editing

2. Home Plan Responsibilities

• Benefit accuracy
• Prior authorization
• Duplicate check
• Coordination of benefits
• Clinical review, including:
  • Medical necessity review
  • Medication review
  • Level of care review
• High-Dollar payment approval/signoff process

Medical Records

When a claim is allowing $1 million or more, timely submission of all requested medical records is mandatory for a pre-payment review. Failure to provide these records in accordance with Highmark's policies and/or contractual terms will result in claim denial.

Once medical records have been received, the claim audit will resume.

Further Evaluation

The $1 million threshold will be evaluated by the BCBSA in 2028 to determine if further changes are needed.