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Reimbursement Policy: Pricing and Adjudication Principles – Overpayment Recovery Window July 01, 2025 Claims & Coding

Effective September 1, 2025, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is updating its Pricing and Adjudication Principles reimbursement policy.

Blue Cross NC will be expanding the overpayment recovery lookback window from 24 months to 36 months. Reminder, instances of fraud, misrepresentation, intentional misconduct and statutory or regulatory compliance and unsolicited or self-reported refunds already have an expanded lookback window. Please see the related policy notification for more information.  

Blue Cross NC is implementing this change to ensure consistent reimbursement practices and enforce guidelines regarding appropriate pricing and adjudication principles. This aligns with Blue Cross NC’s mission to make healthcare more affordable for all. This policy update applies to Medicare Advantage.  

Disclosures:

Blue Cross and Blue Shield of North Carolina Senior Health, DBA Blue Cross and Blue Shield of North Carolina, is an HMO-POS D-SNP plan with a Medicare contract and a NC State Medicaid Agency Contract (SMAC). Enrollment in Blue Cross and Blue Shield of North Carolina Senior Health depends upon contract renewal.

NCBCBS-CR-082525-25-CPN81329 June 2025

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

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© 2025 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.