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A Reminder for Orthopedic Providers

With the exception of covered clinical trials, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will not provide coverage for investigational (experimental) services. Please see our Clinical Trial Services Policy for more information about what is covered.

Investigational (experimental) services do not meet the criteria for “medically necessary services” because these services are not standard medical practice. Please see our Medical Necessity Policy and the Blue Cross NC Corporate Medical Policy titled “Investigational (Experimental) Services” for more information.

You can also learn more about all of our corporate medical policies here.

More information about non-covered services can be found in:

  • Our provider contracts
    In the “Payment to You” section, you agree not to bill, charge, seek compensation, remuneration, or reimbursement from any member, us, or any third party for health care services, and/or supplies provided to members which are determined by us not to be medically necessary, or are not payable due to your failure to follow our applicable policies and procedures, except as provided in Section 4.5.6 (Member’s Written Authorization Required) or as otherwise required by law.
  • Our provider Blue Book
    • Section 9.7 states that Blue Cross NC does not cover investigational (or cosmetic) services, and will not reimburse for any services, procedures, or supplies associated with those investigational (or cosmetic) services.
    • Section 9.14 states a service that Blue Cross NC verifies as non-covered for a specific member may be billed to the member when the provider has advised the member in advance of providing the service that the service will be non-covered, and the member has agreed to pay the provider under the conditions specified within the hold harmless provision of the provider’s agreement with Blue Cross NC. The hold harmless provision can be found in section 9.17.
    • Section 9.14.1 states providers may not bill or otherwise hold members responsible for payment for services which are deemed by Blue Cross NC to be out of compliance with Blue Cross NC’s Care Management and Operations programs, and policies or medical necessity criteria are otherwise non-covered, except as outlined within the chapter 9 instructions for billing members as a non-network provider.