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Enhancement of claim submission and reimbursement policy disclosure

In our continued effort to inform providers of our claim submission and reimbursement policies, and in compliance with House Bill 1066, which amends Article 3 of Chapter 58 of the North Carolina Statutes, BCBSNC has implemented Clear Claims Connection (CCC).

CCC is a software application that outlines claims payment policies, related rules, clinical edit clarifications and source information for providers. It allows providers to review ClaimCheck auditing rules and clinical rational by simulating how ClaimCheck evaluates code combinations.

This tool is available online to all contracted providers through Blue–e, and utilizes version 32 of ClaimCheck. The information contained in this application pertains only to Blue Care®, Blue Choice®, Blue OptionsSM and Blue Advantage® (members with alpha prefix of YPP) and Classic Blue®.

Certain plans are not covered by House Bill 1066, including administrative services only (ASO), Federal Employee Program, State of North Carolina Teachers’ and State Employees’ Comprehensive Major Medical Plan (State Health Plan), BlueCard Host, and Medicare Supplemental. However, BCBSNC uses ClaimCheck to audit ASO claims, so CCC can be used to understand how ClaimCheck auditing works for these claims.

The law also does not apply to claims processed by third parties, including Magellan Behavioral Health, claims for pharmacy services processed by Merck–Medco Managed Care LLC, and claims for dental services processed by Dental Benefit Providers, Inc., or ASC Benefit Services, Inc.

Description of our reimbursement policies can also be found in your Provider Manual for Physician Offices. If you have any questions, please contact your local Network Management office.