New and Enhanced SMA Reimbursement Policies

With our Medicare Senior Market Administration (SMA) line of business moving to a different claims platform effective January 1, 2024, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has updated policies to align with this migration.

Blue Cross NC has three new reimbursement policies for the following: 

• Nonpayment for Serious Adverse Events (PDF)
• Opioid Treatment Program Reimbursement (PDF)
• Reduced and Discontinued Services (PDF)

In addition to the above new policies, Blue Cross NC has added enhanced language to existing policies. These updates are in alignment with Centers for Medicare & Medicaid Services (CMS) coding guidelines and instruction and exampled below:  

• Drug & Biologicals (PDF) – Coding guidance has been added to the Reimbursement Guidelines section with guidance for the reimbursement of administration fees.

All policy content can be found on the Blue Cross NC website’s January 1, 2024, notification.

This communication applies to Medicare Senior Market Administration (SMA) line of business.