Physicians/Specialists
Facilities/Hospitals
Publication Date: 
2020-11-09

Starting Jan. 1, 2021, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will conduct routine reviews on high-dollar, Host Blue Card® inpatient claims on a pre-pay basis and will require itemized bills from your facility when services are billed or priced over $100,000.00 and meet criteria listed below:  

  • The claim is for any insured Blue Card member with health care coverage from another Blue Plan (i.e. not a Blue Cross NC member and not a Medicare Supplemental, Medigap, Medicaid, or Federal Employee Program member).   

  • The claim is for inpatient services for participating acute care facilities only. 

  • The claim has a billed or expected allowance greater than or equal to one-hundred thousand dollars ($100,000.00). 

  • The claim's anticipated reimbursement does not include Per Diem, Flat Fee Case, or a DRG rate, unless priced based on percentage-of-charge. 

  • The claim is received by Blue Cross NC on or after Jan. 1, 2021.  

We're implementing this change to comply with a requirement from the Blue Cross and Blue Shield Association, which mandated that all Plans, including Blue Cross NC, lower their high-dollar reviews for inpatient claims submitted for Host Blue Card members from $200,000.00 to $100,000.00.    

Avoiding processing delays 
Potential claim processing delays can be avoided by sending itemized bills to Blue Cross NC in conjunction with the filing of facility claims, when reporting inpatient services provided to Host Blue Card members and the amount billed is greater than or equal to $100,000.00. 

When high-dollar, inpatient claims reporting services for Blue Card members require itemization, please include:  

  • A complete listing and description of all services received and charged 

  • Applicable dates 

  • Codes 

  • Units 

  • Charge amounts. 

If a facility does not submit an itemization when required, the claim will be returned to the submitting hospital with a request for the itemization to be provided.