Physicians/Specialists
Facilities/Hospitals
Publication Date: 
2021-05-17

Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

Effective January 1, 2021, reimbursement policies will become effective and located on the Blue Cross NC provider website. These Blue Cross NC reimbursement policies apply to providers who serve members enrolled in Healthy Blue + Medicare. Blue Cross NC reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, Blue Cross NC strives to minimize these variations. To view the updated reimbursement policies, visit the provider self-service website.

What does this mean to me?

Please refer to the reimbursement policy website, your provider manual and/or your provider contract as a guide for reimbursement criteria. Reimbursement policies serve as a guide to assist you in accurate claim submissions and to outline the basis for reimbursement if the service is covered by a member’s benefit plan. The determination that a service, procedure, item, etc. is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member’s state of residence. Proper billing and submission guidelines are required along with the use of industry-standard, compliant codes on all claim submissions.   

Reimbursement policies undergo reviews for updates to state contracts and federal or CMS requirements. Additionally, updates may be made at any time if we are notified of a mandated change or due to a Blue Cross NC business decision. We reserve the right to review and revise our policies when necessary. When there is an update, we will publish the most current policy to our website.

Code and clinical editing

Blue Cross NC applies code and clinical editing guidelines to evaluate claims for accuracy and adherence to accepted national industry standards and plan benefits. We use sophisticated software products to ensure compliance with standard code edits and rules. These products increase consistency of payment for providers by ensuring correct coding and billing practices. Editing sources include but are not limited to CMS National Correct Coding Initiative, Medical Policies and Clinical Utilization Management Guidelines. Blue Cross NC is committed to working with you to ensure timely processing and payment of claims.

What if I need assistance?

The complete set of policies are available on our website. If you have questions, please visit the provider self-service website, call the number on the back of the member’s ID card or contact your Network Relations consultant.