Medical Record Requests for BCBSNC Medicare Plans
At times, it is necessary for Blue Cross and Blue Shield of North Carolina (BCBSNC) to request medical records as part of the claims review process. Providers are encouraged to respond to requests for medical records as soon as possible. Per CMS guidelines, if information is not received to complete the claims processing, we will mail back the claim to the provider.
To ensure timely processing of claims, BCBSNC has implemented changes to our medical records request policy as it pertains to BCBSNC’s Medicare Advantage plans. These changes are:
- Initial requests for medical records will be sent via ProviderLink fax.
- When BCBSNC does not receive the requested medical records within five days, a second request will be generated.
- When medical records are not received within 10 days following the initial request, BCBSNC will contact your office in an effort to expedite the process.
- When medical records are not received within 15 days following the initial request, BCBSNC will void the associated claim(s) out of the claims processing system. Please note that by providing the supporting documentation with your new claim, this reduces the need for us to request records multiple times.
The process outlined above is applicable only when medical records are needed to process a claim. Neither annual retrospective chart reviews for BCBSNC Medicare Advantage patients or medical record requests for helping to secure Healthcare Effectiveness Data and information Set (HEDIS) credit are impacted by this change.
We appreciate your prompt response to our requests for medical records when they are needed to complete a claim review. As a reminder, when clarification for a service is necessary and supporting documentation is not provided in a timely manner, this may result in claim processing and payment delays.