Payment Integrity Program Updates

High Dollar Claim Review Update

For claims over $50,000 and processed based on billed charges, we carefully review each line against an itemized bill to validate appropriate coding, billing, and adherence with Premera payment policies.

Starting January 1, 2026, we will cap payment integrity fees for high-dollar reviews. Fees will still be a percentage of savings but capped at $60,000 per claim. January 2026 invoices will reflect this update.

Routine Test Management Program begins February 2026

On February 6, 2026, Premera Blue Cross Blue Shield of Alaska will launch the Routine Test Management (RTM) program. The program reviews certain laboratory claims using laboratory policies based on the latest science and clinically accepted, peer-reviewed laboratory services guidelines. The reviews ensure lab services are appropriate, cost-effective, and meet industry standards. This helps reduce unnecessary tests and supports better health for members.

Why it matters

Over 14 billion lab tests are done in the U.S. each year— making it the most utilized medical benefit. Without clear standards, tests can be misinterpreted or misused. Unnecessary tests can put members at risk. They may lead to extra sample collection, false results, and treatments that aren’t needed. With routine test management, Members get only the tests they need, reducing risks from extra procedures.

How it works

• Claims are reviewed after service but before payment. Automated tools check for:
  • Procedures that can’t be done together
  • Limits on frequency and units
  • Age and clinical appropriateness
  • Required add-on procedures
• Tests from emergency rooms, hospital stays, or observation settings are excluded from review.

For questions about this or other payment integrity programs, please contact your Premera account manager