Update: (November 10, 2023)
A recent system upgrade caused CERIS claims to close, making them not visible online through Availity. This occurred from October 21 through November 9, 2023. Claims qualifying for CERIS review after November 9, 2023, will display the appropriate denial code and state that the claim has been sent to CERIS.
October 5, 2023
Enhancements to Claims Transparency for CERIS Review
In response to provider feedback, we’re providing better transparency regarding high-dollar claims being reviewed by CERIS.
New process begins October 10, 2023
Starting October 10, 2023, Premera is providing better transparency for claims under review with CERIS. Premera will no longer close claims being reviewed by CERiS but will deny the claim with a remark advising providers that they’ll be contacted by CERIS to provide an itemized bill for review.
Here’s a summary of the new process that begins on October 10, 2023:
- A claim that meets criteria receives a claim level denial EA5. The reason/remark code says: EA5 - Member: No action required. Provider: This claim requires an itemized bill review which will be requested by our third-party vendor.
The claim will then be sent to CERIS.
- CERiS sends a request for an itemized bill to the provider indicating that a claim can’t be processed until the itemized bill is received.
- The provider sends the itemized bill to CERiS.
- CERIS performs the review (within 7 days) and reports its findings to the provider and Premera.
- Premera adjusts the claim based on the CERiS information.
- Commercial claims are adjusted, using the original claim number (with adjustment suffix 01, 02, 03, etc.)
- Host claims are adjusted and assigned a new claim number.
- All claims are released to pay with explanation of payment.
What is CERIS?
CERIS is a third-party vendor that performs itemized bill review on a subset of acute facility claims. The CERIS prepayment review process ensures payment accuracy by identifying errors, duplicate charges, capital equipment, routine services and supplies, unrelated charges, and non-separately billable charges on acute facility claims for inpatient and outpatient services. CERIS information was first communicated in the July 2, 2020, issue of Provider News.
Which claims are reviewed by CERIS?
Claims that meet the following criteria are reviewed by CERIS:
- Acute facility only (inpatient and outpatient)
- Pricing methodologies:
- Percent of billed charges and diagnosis-related group (DRG) outlier
- Allowed amount of equal to or greater than $50,000
- BCBS host and fully insured members
- Washington and Alaska
If you have any questions about CERIS, contact your Premera provider representative.