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New Form for Provider-Initiated Refunds for Out-of-Area Members

When we receive non-requested refunds for out-of-area Blue Plan members, both BCBSNC and the member's Home Plan are involved in the transaction. Because of this coordination with other Blue Plans, it is critical that we receive accurate information whenever you send us a refund for out-of-area members.

So that we can effectively represent your interest when contacting the Home Plan about a provider-initiated refund, we need sufficient documentation to link a particular refund to a specific claim. When sending provider-initiated refunds to BCBSNC, please use the following checklist to help ensure that all necessary information is provided:

1. Ensure that the amount being returned does not exceed the amount paid for the original claim.

2. Provide Explanation of Benefits (EOB) documentation for any insurance carrier associated with the claim for which a refund is being provided.

Ensure that the EOB documentation includes:

• Provider's name
• Provider's BCBSNC ID number
• Policyholder's full name
• Policyholder's ID (include prefix and number)
• Patient's full name
• Patient's date of birth
• Original claim number
• Date of service
• Amount of charge for the original claim
• Amount paid for the original claim
• Date of payment for the original claim
• Amount being returned against the original charge

3. Provide one of the following specific reasons for the refund:

• Duplicate payment (requires both BCBSNC vouchers)
• Worker's Compensation (provide the date of onset)
• Medicare payment is primary (need EOB)
• Other carrier paid primary (need EOB)
• Corrected claim / billed in error (need copy of claim)
• Filed under wrong patient (need copy of claim)
• Incorrect date of service (need corrected claim)
• Medicare adjusted payment (need EOB)
• Other carrier adjusted payment (need EOB)
• Not your patient

4. When applicable, provide a corrected claim form.

5. Supporting documentation must include:

• Copy of the original claim
• Original Notification of Payment (NOP)
• If sending a refund as a rebuttal to a payment issue previously discussed with BCBSNC, please attach a copy of the information described above, as well as a copy of the BCBSNC check voucher to the check.

Organizing and providing this information will allow BCBSNC to process your initiated refund more efficiently and accurately. Refund checks received without the necessary support information will be returned to the provider. To further assist you, BCBSNC has created the Host Plan Provider-Initiated Refund Form, which should be attached to every provider-initiated refund and used as a checklist to help ensure that all necessary information is provided.

Please submit all Provider-initiated refunds for out-of-area members to us at:

Blue Cross and Blue Shield of North Carolina
Attn: Cashiers Department
P.O. Box 30048
Durham, NC 27702-3048