Submitting medical necessity review records for commercially-insured members
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
Medical records submission and reporting
These instructional guides will help providers anticipate when the services they've provided will be reviewed by Blue Cross NC for medical necessity. The guides will also help providers understand ways to submit medical records for reviews.
If medical records are needed to support a medical necessity review and are not received by Blue Cross NC before the claim adjudicates, the member will receive an Explanation of Benefits (EOB), the provider will receive an Explanation of Payment (EOP), and both will receive a claim denial letter addressing the specific reason(s) for the denial. The denial letter will provide reference to the criteria on which the denial decision was based, and will inform the member and provider of their rights and ability to appeal the decision.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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