Publication Date: 

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).

Blue Cross NC strives to ensure Healthy Blue + Medicare providers understand documentation  compliance, and we are committed to educating Healthy Blue + Medicare providers in hopes of eliminating errors in documentation practices. It is a best practice and industry standard that physicians sign and date laboratory orders or requisitions. 

Although the provider signature is not required on laboratory requisitions, if signed and dated,  the requisition will serve as acceptable documentation of a physician order for the testing, and it is strongly encouraged. In the absence of a signed requisition, documentation of your intent to order each laboratory test must be included in the patient’s medical record and available to Blue Cross NC upon request. Documentation must accurately describe the individual tests ordered; it is not sufficient to state “labs ordered.”

Blue Cross NC will consider laboratory order or requisitions requirements met with one of the following:
• A signed order or requisition listing the specific test(s)
• An unsigned order or requisition listing the specific test(s), and an authenticated medical record supporting the physician’s intent to order the test(s)
• An authenticated medical record (for example, office notes or progress notes) supporting the physician’s intent to order the specific test(s)

Attestation statements are not acceptable for unsigned physician order or requisitions.
Signature stamps are not acceptable.

• Title 42 CFR §410.32
• Reimbursement Policy C-20003 ; Documentation Standards for Episodes of Care –
Professional Administrative 

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is an independent licensee of the Blue Cross and Blue Shield  Association. All other marks are the property of their respective owners. 
NCBCBS-CR-005980-22-CPN5368 September 2022