Routine Review of Clinical Information

Blue Cross and Blue Shield of North Carolina (BCBSNC) may require the submission of clinical information for adjudication of a Physician's claim for payment. This may include claims that fall into the Plan's claims categories of pre-existing conditions, as defined by the Member Guide or medical necessity as determined by the Plan's Corporate Medical Policy. Other claims that may require clinical information are for services filed with unlisted or miscellaneous codes, which should be submitted with a written report, as supported by the CPT/HCPCS manuals.

BCBSNC also requires submission of medical records for review of codes on the prior plan approval list. Clinical information is used for many reasons, such as medical necessity, potential discharge or case management needs. In addition, we require relevant clinical updates for members receiving services in order to effectively meet their needs.