Yes. Medicare Advantage members can request an appeal, and the appeal process defined by Medicare has not changed. Providers may also submit an appeal on a member’s behalf, as permitted under Medicare regulations.

Call 888-296-9790 and a Blue Cross NC representative can assist you.

The member appeal will take precedence and the provider appeal will be closed. The provider will receive a letter notifying the provider that their case has been closed because the member has filed an appeal.

You have 90 calendar days from the claim adjudication date to submit a Level I post‑service provider appeal.

Electronic transactions are data exchanges sent electronically between payers, healthcare providers, and clearinghouses. HIPAA requires the use of specific standards for these transactions, which include:

• Claims and claim status
• Remittances (such as payments and explanations of payment)
• Eligibility inquiries and responses
• Authorizations and referrals

Using these standards helps ensure transactions are processed consistently and accurately across healthcare systems.

We accept any data values that meet HIPAA standards. However, only certain data elements and values are required for us to process a transaction. Those requirements are outlined in the Blue Cross NC Companion Guide.

HIPAA allows payers to receive all required data, even if they only use certain data elements for processing, as long as those requirements are clearly documented. By documenting those requirements in the Companion Guide, we stay compliant with HIPAA and help you submit transactions that process correctly.

If you are a company that sends transactions on behalf of health care providers or you are a large provider institution that submits transactions on behalf of multiple provider groups, you will need to identify each group Blue Cross NC Provider ID for which you transmit files. However, you can send all group provider identifiers for which your organization is responsible on one form, using additional sheets of paper if necessary. However, separate forms must be submitted for 837 Institutional Provider Identifiers and 837 Professional Provider Identifiers.

No. However, a newly credentialed practitioner should be assigned a Blue Cross NC Provider Identifier Number by Network Management, another department of Blue Cross NC. Contact your local Network Management field consultant for more information.

The TPA outlines the roles and responsibilities that bind both Blue Cross NC and its trading partner, to ensure secure electronic transmissions. A TPA is not required by HIPAA, but the ASC Insurance Subcommittee that was charged with developing the Implementation Guides for EDI transactions strongly recommends that trading partners have binding agreements to provide security and assurance in the transfer of electronic information (See Section 1.1.1 of any ASC X12 Implementation Guide). Blue Cross NC has made a business decision to make trading partner agreements a requirement for EDI transmission based on this recommendation.

What’s required depends on whether you send transactions directly to us or transmit them through another organization.

If you send transactions directly to Blue Cross NC:

You’ll need to complete the following steps:

• Complete a Blue Cross NC Trading Partner Agreement (TPA). A TPA is required even if testing isn’t needed.
• Return an original copy of the TPA, signed by authorized personnel, to Blue Cross NC EDI Services.
• Complete an Electronic Connectivity Request (ECR) form for each transaction type you want to transmit.

If you send transactions through a clearinghouse, billing service, or service bureau:

• Complete an ECR form for each transaction type you want to submit or receive.

Your clearinghouse or service bureau may complete and submit the ECR form on your behalf.

TPA and ECR forms and additional instructions are available on the HIPAA information page.

If you or an organization transmitting on your behalf sends transactions directly to us, a Blue Cross NC Trading Partner Agreement (TPA) is still required. Our TPA is designed to be comprehensive and is intended to address the legal and operational requirements for trading partners that submit direct transmissions to us.

You can call the eSolutions HelpDesk at 888-333-8594 to verify the status on your Trading Partner Agreement or ECR.

Right now, only one HIPAA‑compliant transaction version is available for transmission. However, as new versions are approved in the future, multiple version options may be available. Each version will have its own requirements, so including the transaction version number on your ECR form helps ensure we know which version you’re submitting and can process your transmissions correctly.

In most cases, only a small percentage of claims require additional medical documentation. When documentation is needed, you’ll be contacted by letter with instructions.

If you choose to submit supporting information electronically, include it in the NTE segment of the 2300 loop on the 837 claim transaction. This allows the information to be associated with the claim during processing.

Do not send unsolicited medical notes on paper. Paper documentation can’t be attached to an electronic claim and may result in delays rather than speeding up payment.

Blue Cross NC requires that secondary claims be filed after primary claims have been processed and posted to the provider's practice management system. The 837 Health Care Transactions provide for COB (Coordination of Benefits) claims data, and secondary claims should be submitted by batch transaction, just as primary claims are submitted. The 2320 Loop of the 837 contains all COB information.

Yes.

No. If the secondary claim is filed electronically in the 837 format and includes the primary payment information, you do not need to send a paper EOB.

Blue Cross NC invokes security validation edits to ensure that only authorized trading partners and providers are exchanging data with Blue Cross NC. Security validation takes place at both the ISA (Interchange) and GS (Functional Group) Levels of the transmission, as well as the ST (Transaction Set) Level of the transmission.

What portion of the transmission gets rejected depends upon where the violation occurs. If the violation is in the ISA, the entire transmission fails. If it is in the GS portion, the entire Functional Group fails. If a security violation occurs within the Transaction Set, all claims/inquiries associated with the same Provider Identifier that could not be validated fail. See individual chapters of the Blue Cross NC Companion Guide to EDI Transactions for more information.

In the past, we sometimes corrected certain data errors on both paper and electronic claims when the issue involved information we could clearly identify and update. However, due to HIPAA requirements, we can no longer manually correct key data elements.

Today, claims must meet HIPAA Implementation Guide requirements and Blue Cross NC business edits exactly as submitted. Identification numbers, dates of service, place of service, diagnosis codes, procedure codes, and provider numbers can’t be changed manually during processing.

If a claim is submitted electronically with errors in any of these required fields, it will fail edits and be returned to you for correction, even if a similar paper claim may have processed in the past. To avoid rejections and delays, make sure all required data is accurate and complete before submitting the claim electronically.

No. Taxonomy codes are not required for Blue Cross NC adjudication. The PRV segment (Loop 2000A) is not required for Blue Cross NC processing.

No. Each health insurance carrier defines its own business edit and denial codes based on its processing requirements.

If the HIPAA Implementation Guides require specific data elements, those elements must be included in the transaction. We can’t override HIPAA requirements. If required information is missing, the transaction will be rejected before it reaches us for processing because it won’t pass Implementation Guide edits.

To avoid this, work with your software vendor and business staff to ensure all required subscriber information is collected and maintained in your practice management system before submitting the transaction.

Yes. You’ll continue to see this message if the member ID number can’t be validated. We require that member ID numbers be submitted exactly as they appear on the member ID card. For BlueCard^® and Federal Employee Program members, the ID number may or may not include a suffix, depending on the plan.

If the ID number isn’t entered correctly, Blue e may prompt you to provide the exact number, including any suffix. Transactions for these members are routed through Blue Exchange^®, which relies on accurate member ID details for validation and proper processing.

If a segment or data element is required by the HIPAA Implementation Guide, you must include it in your 837 Professional claim – even if we don’t use that data for claim processing.

To ensure your claim passes HIPAA compliance edits, include the required type‑of‑service codes when submitting your 837 Professional claims. Claims that are missing required HIPAA elements may fail Implementation Guide edits and won’t process correctly.

Blue Exchange provides responses in real time – usually within seconds. Response timing depends on the responding Blue plan. You can review returned responses on the Summary Results pages.

Blue Exchange, the data management system shared with Blue Cross and Blue Shield plans around the country, has been available for HIPAA-compliant transactions since August of 2003. Transactions that have been routed through Blue Exchange are already receiving acknowledgments and responses.

No. Different Blue plans use different ID formats, with or without suffixes. So as long as the membership ID you submit matches exactly what appears on the member’s ID card, it will be recognized. 

Yes. However, if the vendor receiving the 835 is different from the one submitting your 837 claims, you must complete a separate 835 Electronic Connectivity Request (ECR) form.

No. We can’t determine whether your clearinghouse or billing service has begun testing. You’ll need to contact your clearinghouse or billing service directly for that information.

We consider new suppliers based on current business needs, existing contractual relationships, and the supplier’s products and services.

Contract duration varies. When a contract is up for renewal, Blue Cross NC may invite qualified suppliers to participate in a bid opportunity. Blue Cross NC reserves the right to continue pre-existing relationships without conducting new bids.

Certification means your organization has been reviewed and confirmed by a third-party certifying agency as a diverse-owned business. Suppliers are responsible for acquiring and maintaining valid certification.

Paired response transactions – including 271, 277, and 278‑11 – are sent back to the entity that submitted the original transaction (270, 276, or 278‑13).

The 835 remittance is returned either:

• To the sender of the 837 claim, or
• To the entity identified on the 835 Electronic Connectivity Request (ECR) form, if the remittance should be delivered to a different recipient.

Specialty medications are most commonly used for chronic diseases such as rheumatoid arthritis and multiple sclerosis. These drugs are generally high-cost drugs, ranging from approximately $6,000 to $350,000 per patient, per year. Most specialty drugs are injectable and require special handling and administration. Specialty drugs are not limited to a specific copayment or coinsurance tier, but can be found in all formulary tier levels.

With this specialty retail drug network, there may be a limited number of pharmacies dispensing these medications. Since some pharmacies may choose not to participate in the specialty drug network, you may need to transfer your prescription for specialty drugs to a participating local pharmacy or mail order pharmacy. Please refer to the pharmacy list.

Members can transfer any remaining refills from their current pharmacy to a participating specialty pharmacy by providing their prescription information to the new pharmacy. The specialty pharmacy will handle the transfer on the member’s behalf or, if needed, contact the prescriber to request a new prescription.

No. Specialty medications are all name brands and not currently available as a generic.

Many specialty medications are covered under a member’s medical benefits and are typically administered in a medical setting. However, some specialty medications are oral or self‑administered and are covered under the member’s pharmacy benefits instead.

Only specialty medications that are covered under pharmacy benefits are included in this network.

If you have a health savings account or coinsurance plan, when you visit a new network pharmacy, your costs may actually be lower. If you have a copayment plan, you will not see an increase in your out-of-pocket cost as long as you visit a pharmacy participating in the specialty drug network.

Yes. When new medications become available in the therapeutic classes, they will be added to the list. Please refer to the specialty medications list.

You may want to consider mail-order delivery of your specialty medication. There are many specialty pharmacies available that will mail your prescription to your home, under refrigeration, if necessary, and will also provide specialty services such as adherence monitoring and refill reminders.

Blue Cross NC members who have pharmacy benefits and use specialty medications must use the specialty pharmacy network for those prescriptions to be covered.

This requirement does not apply to members in Blue Medicare Rx^℠ or the Federal Employee Program^® (FEP).

Additional pharmacies may join the network at any time. Please continue to refer to the pharmacy list to check for updates.

Yes. The pre‑service review process hasn’t changed. If a pre‑service request is denied, you can contact American Imaging Management (AIM), Member Health Partnership Operations (MHPO), or ValueOptions to request a pre‑service Provider Courtesy Review (PCR).

If the PCR is denied, the member may request a Level I pre‑service appeal. If the service is performed and the claim is denied, both you and the member may request a post‑service Level I appeal, depending on the reason for the denial.

If the service is performed and denied as not medically necessary, both you and the member have appeal rights.

If the service is performed and denied due to no prior review, and the charges are determined to be provider liability, the denial is contractual and neither you nor the member may appeal.

Understanding the denial reason helps determine whether appeal rights apply and which options are available.

In most cases, no. The Level I Provider Appeal process has replaced the post‑service Provider Courtesy Review.

No. There is no right for providers to appeal a denial for no prior review. These denials are considered administrative and are not eligible for review.

Call 800-214-4844 and a Blue Cross NC representative can assist you.

You have 90 calendar days from the claim adjudication date to submit a Level I provider appeal.

This 90‑day timeframe applies to both:

• Level I Provider Billing/Coding Disputes, and
• Level I Provider Medical Necessity Appeals.

Submitting your appeal within this timeframe helps ensure it’s reviewed for consideration.

Call 888-296-9790 and a Blue Cross NC representative can assist you.

If you’re a non‑contracted provider, you have 60 calendar days from the date of the Explanation of Payment (EOP) – also referred to as the notice of the organization determination – to submit a post‑service appeal.

If the completed Waiver of Liability statement isn’t received within the appeal timeframe, we'll forward the appeal to the Independent Review Entity (IRE), MAXIMUS Federal Services, Inc., with a request for dismissal.

If we don’t receive the Waiver of Liability form, we can’t accept the appeal. In that case, the appeal case file will be forwarded to MAXIMUS Federal Services, Inc. (the Independent Review Entity, or IRE) for dismissal.

Before sending a case to MAXIMUS, we’ll make reasonable efforts to get the completed form from you within the appeal timeframe.

A non-contract provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the provider completes a Waiver of Liability statement, which states that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal. The appeal must be in writing. 

A third-party vendor cannot file on behalf of the non-contract provider. The non-contract provider must file on his or her behalf.

The Waiver of Liability statement confirms that the member won’t be held financially responsible if you lose the appeal. A signed Waiver of Liability must be included with the appeal file you submit to us.

If the signed form isn’t received within the appeal timeframe, the appeal will be forwarded to the Independent Review Entity (IRE), MAXIMUS Federal Services, Inc., for dismissal.

You can find the Waiver of Liability statement in the appeal materials we provide or with the appeal instructions for the specific case.

If your practice is a BlueHPN provider, all providers under that practice are considered participating in the BlueHPN product. To confirm participation details, check with your office manager or contracting representative. You can also use the Find Care tool or call the Provider Blue Line at 800‑214‑4844 for assistance.

BlueHPN health care providers are measured individually and at an aggregate network level. Quality is measured across all aspects of care delivery (e.g., inpatient, outpatient) and within each provider type (e.g., primary care, specialist, hospital or health system). This approach was established because:

• Individual performance results allow us to identify opportunities for improvement and to recognize higher-value care
• Aggregating quality results allows us to understand BlueHPN market level performance in comparison to our BlueCard PPO healthcare provider population

We select quality measures that address key healthcare challenges in each local market, prioritizing measures that align with community health disparities, or those that incentivize better performance in areas that address local needs or challenges. For example, diabetes management might be a critical quality indicator in one community while improving immunization adherence is higher priority in another.

When selecting national measures for BlueHPN, we identified measures that:

• Are aligned with industry-recognized standards, such as the Catalyst for Payment Reform
• Are most commonly used to establish healthcare provider accountability for better patient outcomes
• Closed clinical care gaps, impact longevity and quality of life and/or lower costs
• Spanned care settings and provider types (primary care, specialists and hospitals) to provide a more holistic view of clinical quality performance
• Accounted for regulatory and/or state mandates
• Created a foundation and framework for continuous improvement

Call the Provider Blue Line at 800‑214‑4844 to confirm your practice information is current and displaying correctly in the Find Care tool.

Review the patient’s Blue Cross NC ID card. BlueHPN members will have Blue High Performance Network and the BlueHPN suitcase logo on the front. If those indicators are not present, the patient is not enrolled in BlueHPN.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) contracts with health care providers to be in BlueHPN. Your office manager or contracting manager / representative will have information on the networks you participate in, including BlueHPN.

As a BlueHPN health care provider, your practice will appear on our online “Find Care” tool when a provider search is done in your geographic area. If you would like to confirm this, we can instruct you on how to conduct a search using the “Find Care” tool, or please reference the instructions below. Please contact the Provider Blue Line at 800-214-4844 if you need additional assistance.

• Click the "Look up a Doctor or Drug" button from our Find Care page.
• Log in to Blue Connect or browse as a guest.
• Select the "Doctor or facility" button.
• Once redirected, choose the Blue High Performance Network plan from the drop-down Network box at the top of the page.
  • Once the plan has been selected, select the care you need.
  • You also have the option of a keyword search in the Search field.
    
  • If using the search field, type your practice or provider name in the search field.
  • Once you have selected your practice or provider name that meets your search, click on the provider name to find more details on the profile, and verify BlueHPN par status under the plans accepted section. If not using the search field, the steps below outline directions to browse by Medical Specialty.
  • Click the appropriate item that suits your practice (e.g., Medical Specialties).
  • Click the appropriate medical specialty (e.g., Specialist).
  • Click the appropriate specialist category (e.g., Dermatology). Each item represents a group of certain types of providers.
  • Select the item that appropriately suits your needs. A listing of the selected specialists appears. This list can span multiple pages.
  • Once you have selected the type of provider that fits your search, click on the provider to find more details on their profiles, and verify BlueHPN par status under the plans accepted section.

BlueHPN quality measurements are designed to evolve over time. As provider performance improves and care models change, quality measures may focus more on outcomes. We’ll continue working with you by sharing data and insights to help you understand performance expectations and support ongoing improvements in care quality and affordability.

BlueHPN is currently closed to network additions. When the anchoring health systems and Blue Cross NC developed these networks, we did an intensive analysis of network adequacy, accessibility, and marketability, incorporating both CMS and NCDOI guidelines. We review network adequacy for each product annually. If you have further questions or concerns, please call Provider Blue Line at 800-214-4844.

If you are a Blue Distinction Specialty Care (BDSC) or Total Care designated healthcare provider and have a signed agreement to participate in BlueHPN, you are considered a BDSC and/or Total Care Designated Health Care provider. Please contact the Provider Blue Line at 800-214-4844 if you have any further questions.

It depends on whether BlueHPN patients are included in your value-based contract with us. To confirm how BlueHPN patients are handled and whether they’re attributed under your contract, contact your Blue Cross NC contracting representative.

There isn’t a single quality performance threshold that applies to all healthcare providers. Inclusion in BlueHPN is evaluated using quality performance requirements that reflect local, regional, state, and national benchmarks. This approach helps account for differences in local healthcare needs and population health priorities. Quality performance criteria may change over time as these needs evolve.

Please contact Blue Cross NC by using the Provider Blue Line at 800-214-4844. There are exceptions to make sure your BlueHPN patients get the care they need. Naturally, our priority is the health of our members.

Before referring your patient, use the Find Care tool to identify specialists who participate in BlueHPN. This helps prevent unexpected out‑of‑pocket costs for your patient.

If you’re unable to find an appropriate in‑network specialist for your patient’s condition, contact the Provider Blue Line at 800‑214‑4844. Exceptions may be available to help ensure your BlueHPN patients get the care they need.

BlueHPN members have limited out-of-network benefits. Eligibility and benefit checks, pre-service review, and claims submission processes are the same. 

At this time, BlueHPN^℠ is only offered to Administrative Services Only (ASO), Self-Funded commercial employer groups. It is not available for fully insured / individual U65 groups, State Health Plan (SHP), Medicare, Federal Employee Program^® (FEP), or Medicaid patients.

Care provided at a facility without a Blue Distinction Center designation may still be covered under the member’s benefits. However, out‑of‑pocket costs may be higher, especially if the facility is outside the Blue Cross NC network. To confirm which services are covered and what costs may apply, members should call us using the number on their ID card.