Blue Cross and Blue Shield of North Carolina (Blue Cross NC) recently announced plans to begin accepting the upfront submissions of medical records to help support the medical necessity of services already provided to our commercially insured members. Accepting medical records upfront represents a process change for the way Blue Cross NC previously handled unsolicited records.
Beginning December 1, providers will be able to proactively send medical records to Blue Cross NC in advance of claims being processed. This will help avoid medical necessity denials, which result from Blue Cross NC not having required medical necessity information. We are making this change to better align our administrative processes for medical records with guidance from the National Committee for Quality Assurance (NCQA).
This new process ONLY applies to Blue Cross NC’s commercially insured membership, including administrative-services only (ASO) groups and the State Health Plan. Federal Employee Program members, Blue Cross and/or Blue Shield members eligible through the BlueCard® program, and members enrolled in Blue Cross NC’s Medicare Advantage plans are excluded.
Before sending medical records to Blue Cross NC, please consider if the records are required and if the documentation will be sufficient to meet criteria for a given service. These criteria are outlined on Blue Cross NC’s online Medical Policies website for Blue Cross NC’s commercially insured members. Blue Cross NC’s medical guidelines are written to cover a given condition for the majority of people. However, each individual's unique clinical circumstances may be considered in light of current scientific literature, as well as an individual member’s coverage and eligibility for a particular service or supply.
Medical records are typically needed by Blue Cross NC for the following:
- To review the medical necessity of a specified CPT, HCPCS or revenue code.
- To determine unlisted services.
- To identify a durable medical equipment price from the invoice.
- To determine the name of a physician who has ordered labs.
- To determine a member’s benefit.
- To identify a national drug classification (NDC) for a medication.
To help providers anticipate when the services they’ve provided will be reviewed by Blue Cross NC for medical necessity, as well as to understand the methods to submit medical records for such reviews, we’ve developed the following instructional aides to help guide you:
- How to Submit Medical Records for Medical Necessity Reviews
- Service Categories Most Frequently Requiring Medical Record Submissions
- Codes by Procedure Types Requiring Medical Records Submissions
- ICD-10 Diagnosis Codes Associated With Revenue Code 0360 and Requiring Medical Records Submissions
After December 1, 2015, if medical records are needed to support a medical necessity review, and records were not received by Blue Cross NC before the claim is processed, the member will receive an Explanation of Benefits and the provider will receive an Explanation of Payment showing the specific reason(s) for the claim denial. The denial letter will provide reference to the criteria on which the claim denial decision was based, and it will inform the member and provider of their rights and ability to appeal the decision.