Physicians/Specialists
Facilities/Hospitals
Ancillary
Publication Date: 
2019-11-08

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) offers the level 1 post-service provider appeals process to providers for denied claims when services have already been provided to commercially-insured members and the claim was denied for the following reasons:

  • Not Medically Necessary
  • Cosmetic
  • Investigational/Experimental
  • No Authorization for Inpatient Admission
  • Coding/Bundling Denials:
    • Incidental
    • Integral Part of Primary Service
    • Mutually Exclusive
    • Rebundling
    • Service Not Eligible for Separate Reimbursement
    • Surgical Global Period Denial

If your claim is not denied for one of the reasons noted above, there are no provider appeal rights available.

Provider appeals must be submitted using the Level 1 Provider Appeal Form within 90 days of the claim adjudication date. These guidelines apply to Blue Cross NC's commercially-insured, under-65 products, including ASO products and the North Carolina State Health Plan.