Reminder: High Dollar Pre-payment Review Process

March 3, 2026

BlueCross BlueShield of South Carolina and its subsidiary plans have the high dollar pre-payment review (HDPR) process 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.

The dollar amount for HDPR includes inpatient institutional claims with an allowed amount of $100,000 or greater for all plans, except for Group and Individual.

The dollar amount for Group and Individual plans includes claims with an allowed amount of $75,000 or greater. Review the list identifying the alpha prefixes and group number prefixes associated with these plans to ensure the necessary itemized bill is being provided.

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 $100,000 or greater (or $75,000 for Group and Individual plans).
Any pricing methodology that involves a discount except for:
- Per-diem
- Flat-fee case rate
- DRG rate

When requested, submit the itemized bills through My Insurance Manager℠ using the claims attachment feature. Be sure each line of the itemized bill includes a clear description, including the name and dose of medications, names of supplies, any applicable CPT or HCPCS codes and the revenue code associated with each line. To prevent delays in reviewing the itemized bill, ensure that it is legible upon submission.

Note: Medical records are not needed and cannot be submitted in lieu of the itemized bill.

Example of an Acceptable Itemized Bill

42 Rev. Co.	43 Description	44 HCPCS/Rate/HPPS Code	45 Serv. Date	46 Serv. Units	47 Total Charges
0250	Midazolam 10 MG	J2250	010326	2	29.09
0272	Guidewire 3CM	C1769	010326	1	3597.00
0278	Device Closure	C1760	010326	1	2563

Example of Unacceptable Itemized Bill

42 Rev. Co.	43 Description	44 HCPCS/Rate/HPPS Code	45 Serv. Date	46 Serv. Units	47 Total Charges
	Pharmacy		010326	336	7780.81
	Sterile Supply		010326	8	7680.40
	Supply/Implants		010326	2	6358.00

What Happens During the Process

During the review process, charges on the itemized bill are identified as not separately reimbursed based on the application of the Inpatient Non-Reimbursable Charge/Unbundling Policy. The initial charges on the claim will be reduced based on these findings and the covered charges on the claim will be processed for payment according to the contract.

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