Reimbursement Policy Update: Post-payment Record Requests - Pricing and Adjudication Principles

Effective February 1, 2025, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is updating its post-payment record request process.

When medical records are requested during a post-payment review, the records must be received within 60 calendar days. If the requested documentation is not received, the claim will be subject to a technical denial, and funds may be recouped or adjusted against future payments. For claims receiving a post-payment technical denial for lack of records, providers may submit a reconsideration request with the requested records following instructions listed in the denial notice. Please see the related Commercial and Medicare Advantage policy notification for more information. 

This change is being made to support existing post-payment review record requests. When additional context is needed to verify the information on a claim, Blue Cross NC will request records for further review. When records are not received, Blue Cross NC is not able to validate the claim details in question and payment of the claim will be rescinded. This aligns with Blue Cross NC’s mission to make healthcare more affordable for all.

This change will apply to Commercial, Medicare Advantage, Inter-Plan Program (IPP) Host, and Federal Employee Program (FEP). It will not apply to IPP Home.