Blue Medicare Pricing Platform Update

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is committed to offering competitive options for affordable health care coverage in North Carolina. To do this over the long term, we must ensure our policies and procedures are aligned appropriately with industry standards.  Upon careful consideration and review of our procedure pricing software, Blue Cross NC will be transitioning from Burgess to Optum.

Blue Medicare currently uses two vendor-based solutions for Medicare Advantage claims pricing.

The Optum Pricing Module is used for facility claims and certain other module pricing (Ex - Home Health, ESRD, etc.) that is integrated with Blue Cross NC claims processing system.

The Burgess pricing solution is used for professional claims and is not integrated with Blue Cross NC claims processing system.

In 2022, we will be retiring the Burgess pricing solution and using the Optum Pricing Module for both facility and professional claims. Consolidation to a single vendor will reduce administrative complexity of managing a separate vendor and contract, as well as, align with more frequent CMS pricing updates and industry standards. This change will allow for full integration with the Blue Cross NC claims processing system.

This transition began with our non-participating Blue Medicare providers beginning in Q1 2021 and will expand to participating providers beginning in Q2 2021 until all providers are transitioned.

If you have questions regarding this update, please contact Blue Cross NC at 800-777-1643, choose option #6 or email NM.Contracting@bcbsnc.com.