High Dollar Threshold Change for Blue Cross NC Members and How to Submit Applicable Medical Records and Itemized Bills for Blue Cross NC Member High Dollar Review

Effective July 16, 2024, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will now consider all claims with total charges of $100,000 or greater on Blue Cross NC Members as High Dollar claims requiring Medical Review. These claims will require Itemized Bills and applicable medical records to be submitted with or prior to the claim submission. Claims received without the required documentation will have an electronic mail back of the claim for resubmission of a new claim to be processed when records are available.

This will be applicable for the Commercial line of business including the State Health Plan which will match what is already occurring for Host members.

If submitting the claim electronically, please submit the itemized bill and applicable medical records in advance of filing the claim. By sending this supporting documentation first, Blue Cross NC will be able to locate and match it to the claim. Submitting the claim before the itemized bill has been received by Blue Cross NC will create the potential risk of the claim being mailed back due to missing required information.

Blue Cross NC can accept itemized bills and applicable medical records to support electronically submitted claims via the following methods:

1. The secure on-line message system ProviderLink
2. Fax transmission via:
   a.  844-340-5055 - Blue Cross Blue Shield of NC - Commercial
   b.  844-340-5244 - Blue Cross Blue Shield of NC - State

In addition, Blue Cross NC will continue to accept claims accompanied with itemized bills and applicable medical records via mail.

For providers with an active ProviderLink On-Line Contract

• Please use the following instructions for submitting itemized bills for Blue Cross NC member high dollar reviews via ProviderLink On-line.
• Providers can use the ‘on-line’ message feature to submit itemized bills independent of the claims. Please identify the message type by entering “High Dollar Records and Itemized Bill” as the message subject.
• Please ensure that the following information is clearly documented in the ProviderLink On-Line message header:
  • Patient’s name
  • Patient’s member ID Number (including the Prefix and Suffix) in the Unique ID field
  • Patient’s Date-of-Birth
  • Date(s)-of-Service
  • Sender’s name and direct phone number on the message header (Blue Cross NC will contact the individual listed if there are any questions about the received document)
• Please do not “Request a Reply” to the message when submitting the pro-active itemized bill. Blue Cross NC recommends utilizing the Audit Trail feature within the application.  Contact OpenText for additional information about “Audit Trail” features.
• Submit the itemized bill to the ProviderLink On-Line mailbox, identified as “High Dollar Records and Invoices.”

Submitting itemized bills via fax for an electronically submitted claim

Please use the following instructions for submitting itemized bills for Blue Cross NC member high dollar reviews via fax.

1. Create a fax cover sheet containing the following information:
   a.  Patient’s name
   b.  Patient’s member ID number (including the Prefix and Suffix)
   c.  Patient’s date-of-birth
   d.  Date(s) of service
   e.  Total charge
   f.   Sender’s name and direct phone number (Blue Cross NC will contact the individual listed if there are any questions about the received document)
   g.  Subject:   Blue Cross NC Member High Dollar Medical records and Itemized Bill
2. Fax the cover sheet followed by the itemized bill to the appropriate fax number based on line of business:
   a.  844-340-5055 - Blue Cross Blue Shield of NC - Commercial
   b.  844-340-5244 - Blue Cross Blue Shield of NC - State
3. Please do not “Request a Reply” to the message when submitting the pro-active itemized bill; requesting a reply causes the patients’ files to be assigned to a specific work list within the Blue Cross NC application and will cause additional and unnecessary incoming messages within the system. Blue Cross NC recommends utilizing the Audit Trail feature within the application.  Contact OpenText for additional information about “Audit Trail” features.
4. Submit the itemized bill to the ProviderLink On-Line mailbox, identified as “High Dollar Records and Invoices.”

Submitting claims and itemized bills via mail
To submit high-dollar claims via mail, please mail the claim, applicable medical records, and associated itemized bills using the appropriate coversheet to:

Blue Cross Blue Shield of North Carolina
PO Box 35
Durham, NC  27702