Publication Date: 

These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by Blue Cross and Blue Shield of North Carolina (Blue Cross NC) if the service is covered for Healthy Blue + MedicareSM (HMO D-SNP) members. 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. You must follow proper billing and submission guidelines. You are required to use industry standard, compliant codes on all claim submissions. Services should be billed with CPT® codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to participating providers and facilities; a non-contracting provider who accepts Medicare assignment will be reimbursed for services according to the original Medicare reimbursement rates.

If appropriate coding/billing guidelines or current reimbursement policies are not followed, Blue Cross NC Medicare Advantage may:

  • Reject or deny the claim.
  • Recover and/or recoup claim payment.
  • Adjust the reimbursement to reflect the appropriate services and/or procedures performed.

Blue Cross NC Medicare Advantage 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 These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements.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 Medicare Advantage strives to minimize these variations.

Blue Cross NC Medicare Advantage reserves the right to review and revise its policies periodically when necessary. When there is an update, we will publish the most current policy to the website.