Blue Cross NC accepts the upfront submission of medical records when the supplied records help document the medical necessity of services or supplies already provided to our commercially-insured members. Providers can proactively send medical records to Blue Cross NC before claims are processed and help avoid medical-necessity denials that may result from Blue Cross NC not having the required medical-necessity information.
The upfront submission process only applies to Blue Cross NC commercially-insured (Blue Cross NC) members, including members enrolled in Administrative Services Only (ASO) groups, and the North Carolina State Health Plan for Teachers and State Employees State Health Plan. Federal Employee Program members and Blue Cross and/or Blue Shield members eligible through the BlueCard® program are excluded, as well as non-commercially-insured members enrolled in Blue Cross NC Medicare Advantage products.
Before sending medical records to Blue Cross NC, please consider if the records are required and if the documentation meets criteria for a given service or supply outlined for Blue Cross NC commercially-insured members on the medical policies page.
Blue Cross NC medical guidelines are written to cover a given condition for the majority of people. However, each individual's unique clinical circumstances may be considered in light of current scientific literature, as well as an individual member’s coverage and eligibility for a particular service or supply. Medical records are most typically needed by Blue Cross NC to:
- Review the itemized invoice for global transplant claims
- Review the medical necessity of a specified CPT, HCPCS or revenue code
- Determine unlisted services
- Identify a durable medical equipment price from the invoice
- Determine the name of a physician who has ordered labs
- Determine a member's benefit, and/or
- Identify a national drug classification (NDC) for a medication
