Effective May 9, 2026, the threshold for manual review of unlisted codes will be updated for all Commercial lines of business (Fully Insured, Under65, Small Group, Large Group, and ASO).
What’s changing
- The dollar threshold that triggers manual review for unlisted codes is decreasing from $400 to $200.
- Any unlisted code with a billed line amount of $200 or more will now be flagged for review.
- This change applies across all Commercial products.
How manual review will work
- Claims meeting the threshold will undergo review for:
- Appropriate clinical documentation
- Correct billing and coding
- Codes will be manually priced under individual consideration.
- This replaces the previous process, in which these codes were allowed to pay at a percentage of billed charges without review.
Why this change is being made
- Ensures more accurate reimbursement for services not associated with a specific CPT/HCPCS code.
- Promotes consistent, appropriate claim adjudication across all Commercial plans.
- Supports clinical and financial integrity efforts.
What providers should do
- Include clear and complete clinical documentation when billing unlisted procedure codes.
- Include unaltered and complete manufacturers’ invoice when billing unlisted DME codes.
- Ensure that billed codes accurately reflect the service performed.
- Expect manual pricing when billed amounts meet or exceed the $200 threshold beginning May 9, 2026.
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.
Information in other languages: Español 中文 Tiếng Việt 한국어 Français العَرَبِيَّة Hmoob ру́сский Tagalog ગુજરાતી ភាសាខ្មែរ Deutsch हिन्दी ລາວ 日本語
© 2026 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.