Update: Medical Record Submission Requirements Paused for Certain CPT/HCPCS and Revenue Codes Filed with Professional or Facility Claims

Update April 9, 2025: Blue Cross and Blue Shield of North Carolina (Blue Cross NC) posted the following communication on February 13, 2025, regarding proactive Medical Record Submissions.  We are committed to partnering with our providers, and in response to the feedback we have received on this medical record submission process, we are rescinding the requirement for proactive records submission for the CPT, HCPCS and revenue codes filed on professional and facility claims linked in the February 13 communication.  While we anticipate the announcement of future medical record submission requirements, we will be working to ensure that the scope is more limited, and the process for such requirements is as efficient as possible. We will provide updates as they become available.

Effective April 18, 2025, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will now require providers to proactively submit all applicable medical records and itemized invoices for any claim filed for certain CPT/HCPCS or Revenue Code found on the Codes By Procedure Types Requiring Medical Records Submission list (PDF). This document is updated quarterly. Instructions for submitting medical records and itemized invoices (PDF) are available.

If records are not proactively submitted, the claim will be rejected and mailed back, and providers will need to file a new, clean claim with the required medical records. Corrected claims will not be accepted once a claim has been rejected for no records. Providers will be notified by EOP if a claim is rejected due to records not being submitted.

Information for resubmitting a claim with medical records is as follows:

• Facility claims filed for surgical procedure must submit Operative Reports, Implant Logs, Circulating Nurses notes, and Itemized Invoice.
  • View instructions for submitting provider-initiated medical records for medical-necessity review (PDF).
  • Please refile as a new claim with the matching records.
• Claims filed with CPT/HCPCS code requiring Medical Necessity review must submit applicable medical records for review.
  
  • View commercial code list for procedure type requiring medical record submission (PDF).
    
  • View instructions for submitting provider-initiated medical records for medical-necessity review (PDF).
    
  • Please refile as a new claim with the matching records.

This new requirement is for all charge amounts and is separate from our previous High Dollar ($100,000 or more) notice posted on 5/16/2024.

This new requirement applies to all Commercial Lines of Business (Commercial, NC State Health Plan) and does not apply to Medicare Advantage.