Enhancement to Current Claims Processing System Beginning June 1, 2022

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) remains committed to correct coding and reimbursement and maintains a suite of widely recognized and transparent payment policies. 

It’s estimated that up to 80% of medical claims contain errors.¹  And whether those mistakes are the result of human error, or deliberate fraud, inaccurate billing can be a costly problem when combined with the increasing cost of health care.  

Starting on June 1, 2022, Blue Cross NC will implement an enhancement to our claims processing system that supports correct coding. The goals of this endeavor are to implement, to the extent possible, claim payment policies that are national in scope, simple to understand and that come from standard sources. Blue Cross NC believes that this will enable you and your billing staff to more readily understand our payment of claims given the widespread use of these policies.   

These enhancements take into consideration Blue Cross NC’s historical claims experience as well as policy guidelines from the following sources: 

• CMS reimbursement guidelines, publications, and policies 
• AMA CPT®, HCPCS, and ICD-10-CMcoding definitions and guidelines 

Blue Cross NC’s payment policies focus on areas such as: 

• National bundling edits including the Correct Coding Initiative (CCI) 
• Modifier usage 
• Global Surgery  
• Add On code usage 
• Maximum units over time 
• Age appropriateness 
• CMS’ National Coverage Determinations 
• National Uniform Billing Committee (NUBC) and Optum Uniform Billing Editor  

For dates of service June 1, 2022 and later, claims will be processed using this updated and industry standard claims adjudication logic. 

1. Gooch, Kelly. (2016). “Medical billing errors growing, says Medical Billing Advocates of America.” Retrieved from Becker’s Hospital Review.