In April of 2020, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) announced a policy to ensure that out-of-network providers would not balance bill members for services related to COVID-19. The policy stated if the provider was seeing a patient in a narrow network that they were not participating with, but the provider had a PPO contract with us, they would be paid at their PPO rate for the services rendered. Due to the passing of the No Surprises Act, COVID-19-related claims that are classified as Surprise Billing or Emergency claims will be paid at the QPA rate, not the PPO rate. 

To that end, Blue Cross NC is establishing the following claims and reimbursement policies for out-of-network providers in North Carolina to ensure access to care for members and reasonable reimbursement for providers. (This applies to claims for COVID-related services.):  

• The following applies to all Blue Cross NC under-65 commercial products, including self-funded and Administrative Services Only (ASO) plans administered by Blue Cross NC, such as the State Health Plan. For Medicare products, we will follow applicable CMS regulations on out-of-network reimbursement.
• For North Carolina health care providers participating in Blue Cross NC’s broad Preferred Provider Organization (PPO) network who are out-of-network for one or more of our smaller network products (such as Blue Value^℠, Blue Home^℠, or any Blue Local^℠ product):  
  • If the claim falls under the No Surprises Act, Blue Cross NC will be paying these out-of-network providers directly at the Qualifying Payment Amount (QPA), as outlined in the legislation.  
  • If the claim does not fall under the No Surprises Act, Blue Cross NC will pay these out-of-network providers directly, at a 100 percent benefit level, priced at the negotiated PPO rates in place with the provider.  
• For North Carolina health care providers who do not participate in Blue Cross NC’s broad PPO network:  
  • If the claim falls under the No Surprises Act, Blue Cross NC will be paying these out-of-network providers directly at the Qualifying Payment Amount (QPA), as outlined in the legislation. 
  • If the claim does not fall under the No Surprises Act, Blue Cross NC will be paying out-of-network providers directly. Blue Cross NC will contact out-of-network providers within 24-48 business hours to gather information needed to process a claim. This fee schedule is based on reasonable rates derived using sources such as Medicare and average in-network rates, depending on the provider type and the applicable codes. Direct payment is not Blue Cross NC’s acceptance of an assignment of member benefits.