In response to provider feedback and the operational impacts shared with us regarding the previous enhanced claims review communication posted on March 2, 2026, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is listening and taking a phased approach to implementing the new enhanced claims review requirements.

Effective May 2, 2026, the Itemized Bill Review (IBR) threshold will be lowered to $75,000. While our ultimate goal remains to lower the IBR threshold to $25,000, we will now do so through a phased approach to allow providers additional time to adjust workflows and minimize administrative disruption.

We appreciate the feedback we’ve received and will continue to engage with providers as we move forward with these changes. Additional details and future milestones will be communicated as they are finalized.

What’s changing

Blue Cross NC will conduct an Itemized Bill Review for all claims with total charges of $75,000 or greater submitted for Blue Cross NC members.

Reviews will occur prepayment consistent with our current process.

Required documentation

For all claims that meet this threshold, providers must submit the following at or before the time of claim submission:

• A complete Itemized Bill, and
• All applicable medical records

If a claim is submitted without all required documentation, it will be denied. The provider will receive notification of the denial via the Explanation of Payment (EOP) to alert more information is required for review.

How to submit

Blue Cross NC accepts Itemized Bills and supporting medical records for electronically submitted claims through the methods outlined in our established submission guidance.

For detailed instructions on submitting Itemized Bills and Medical Records, refer to the official guidance on our website. 

This requirement will apply to all Commercial, Medicare, and IPP Host lines of business. This will not apply to the Federal Employee Program.