Publication Date

Publication Date: 

After suspending claims in February, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) began processing claims again for our individual members in the middle of April.  Claims for these members, which were suspended in Facets (our new technology platform) are being processed in waves, as system configuration challenges are addressed.  Several waves have already successfully processed, and we anticipate the amount of delayed claims will shrink over the next few weeks, as we continue to process additional waves.

We anticipate the large majority of these now-suspended claims will have paid or be scheduled for payment by May 27.  However, we also expect that a portion of these claims will require additional manual intervention for the review of information normally not determined during automated claims processing.  This includes determinations of medical necessity and, as normal, we will pend claims for subsidy-eligible members who are in their grace period, until their premium is paid or the grace period expires and coverage is terminated.  Any additional manual intervention of these suspended claims in Facets should be completed as of mid-July, by which time we expect to be current with our claims inventory and return to normalized processing for new submission claims.

While this is not a widespread issue, it is one of our top priorities and we have dedicated substantial resources to process claims correctly and make payments to providers.  The issue is limited to individual claims handled in Facets.  However, the majority of claims processed by Blue Cross NC are not processed on Facets and Blue Cross NC’s current claims volume not on Facets is being paid normally.  Most of our customers are not impacted.

We understand that while suspended claims in Facets represent a proportionally low amount of all claims processed by Blue Cross NC, some providers may not be receiving as much in payments from Blue Cross NC as they have historically received.  Providers facing financial hardships because of this delay should contact us directly, as we have a dedicated team in place to help.

Providers should contact their Blue Cross NC Strategic Provider Relationships consultant or Susan Menendez, Blue Cross NC director of Strategic Provider Relationships, via email at  Susan’s team will internally guide these requests for individual review and consideration.  Contacting Susan and her team by email will provide us the most efficient means to route requests; however, if it is more convenient, providers may contact any of our strategic provider relationships consultants directly by phone, or call Susan directly at (919) 765-4035.  The only information needed is the provider’s name, the name and contact information of the requestor, and the provider and /or vendor National Provider Identifier(s).

Blue Cross NC will review each situation presented to us by in-network providers.  Providers whose claims payments in 2016 are 20 percent lower than the same time period in 2015 will be eligible for our financial hardship process.  All in-network providers requesting this review will be contacted within one business day to review their eligibility for this program.  Eligible providers can choose to receive a one-time, estimated prepayment through a contract amendment. The prepayment amount will be determined based on the provider’s claims inventory in suspend and will be considered a credit in our system.  Prepayments may also be offered, at our discretion, to in-network providers to ensure our members continue to have access to certain specialized services.  We will issue prepayments to eligible providers following our receipt of a provider’s executed amendment.  The majority of eligible providers can receive prepayments within five business days following their initial request.  We will issue prepayments to eligible providers as soon as one business day following our receipt of a provider’s executed amendment.  Providers may also request payment by check; however, several additional days will be necessary for processing and mailing of checks.

Checking Claim Status

Providers who are awaiting claim payment can check Blue eSM to determine if a claim was received.  Any status that shows the claim is in the system is a reliable means of confirming that we have received it.  If the claim has not yet been paid, that is an indicator that the claim is being held.

Again, please remember this issue affects claims related to services for our individual (under age 65) members, which constitutes a limited percentage of all claims.  Please do not submit duplicate claims, as this will increase our inventory and potentially delay processing time.