Effective May 1, 2025, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) providers will have an extended 90-calendar day timeframe for submitting new disputes and reconsiderations related to certain claims and reviews. This change is not retroactive and does not apply to pre-pay reviews received prior to May 1, 2025, which will continue to follow the existing 45-calendar day review cycle.
We are committed to partnering with our providers, and in response to the feedback we have received on the submission timeline for these requests, we are happy to share the following extensions.
- Vendor conducted post-pay DRG clinical coding reviews
- The dispute period will change from the current 45-calendar day period to 90-calendar days effective May 1st, 2025. Providers should continue to follow the instructions for filing disputes as outlined in the finding letters from Apixio, LLC, and Equian. Providers will begin to see letters reflecting this change from both vendors effective May 1, 2025.
Providers should use the updated forms located under Forms and Documents to submit reconsiderations for the following with the updated 90-calendar day review period.
- Facility Emergency Department Level Reconsideration
- This is a change from the current 45-calendar day period to request a review of a post service claim denied for Facility Emergency Department level.
- Inpatient Readmission Reconsideration
- This is a change from the current 45-calendar day period to submit a written reconsideration request to review a post service claim denied for Inpatient Readmission.
- Itemized Bill Review Reconsideration
- This is a change from the current 45-calendar day period to request a reconsideration of an Itemized Bill Review. Providers will begin to see Itemized Bill Review letters from Blue Cross NC reflecting the updated 90-calendar day timeframe effective May 1, 2025.
This change applies to reconsiderations for all lines of business currently reviewed.
