In accordance with the Centers for Medicare & Medicaid Services (CMS) Final Rule (CMS-4208-F), Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will implement important updates to our Medicare Advantage plans beginning January 1, 2026.  

Inpatient level of care denials

Starting January 1, 2026, the Plan will no longer modify inpatient admission requests to an alternate level of care. If the Plan denies an inpatient level of care, the denial will be treated as an adverse determination, and the member or provider will have appeal rights.

This policy change ensures transparency and consistency in coverage decisions and supports the Center for Medicare & Medicaid Services’ (CMS) goal to protect member rights.

Untimely notification of organization determination

Beginning January 1, 2026, if the Plan fails to issue a timely notice of an organization determination, the delay will be considered an adverse determination. This will automatically trigger appeal rights for the member or provider.

This change is in accordance with CMS regulations, which states that failure to provide timely notice constitutes an adverse organization determination and may be appealed under 42 CFR §422.568 and 42 CFR §422.572.

These changes apply to Medicare Advantage, Experience Health, and Healthy Blue+ Medicare^℠ plans. It does not apply to Commercial Fully Insured, Federal Employee Program (FEP), or Administrative Services Only (ASO) plans.

Additional information regarding CMS Final Rule

What is the CMS Final Rule?

CMS Final Rule is a legally binding set of regulations issued by the Centers for Medicare & Medicaid Services (CMS). These rules represent a final decision to change existing policies to implement new laws or address program improvements. 

What does CMS Final Rule cover?

Final rule covers various aspects of healthcare, such as changes to Medicare Advantage and prescription drug programs, Marketplace integrity, or payment policies for hospitals and skilled nursing facilities. 

Why did I receive denial information if my authorization request has been approved?

A member may receive a letter that appears to indicate a denial of service. Providers will receive a copy of the letter sent to the member.  

This typically occurs when a decision is not made within the timeframes required by CMS. Even if the final outcome is favorable to the member, CMS classifies it as an adverse determination to uphold the member’s right to appeal.

It’s important to note that the letter does not mean that the service is denied. Instead, it serves as a notice informing the member that the plan did not meet the required deadline, which is considered a procedural violation.

In these instances, the service is approved but because the decision was late, CMS requires us to issue a formal notice explaining the delay and outlining the appeal rights. This process protects the member and ensures transparency and accountability.

Who can I contact with questions?

If you receive a letter and have questions, contact customer service using the phone number provided in the correspondence.