Reimbursement Policy: Pricing and Adjudication Principles – Overpayment Recovery Window

Effective September 1, 2025, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is updating its Pricing and Adjudication Principles reimbursement policy.

Blue Cross NC will be expanding the overpayment recovery lookback window from 24 months to 36 months. Reminder, instances of fraud, misrepresentation, intentional misconduct and statutory or regulatory compliance and unsolicited or self-reported refunds already have an expanded lookback window. Please see the related policy notification for more information.

Blue Cross NC is implementing this change to ensure consistent reimbursement practices and enforce guidelines regarding appropriate pricing and adjudication principles. This aligns with Blue Cross NC’s mission to make healthcare more affordable for all. This policy update applies to Medicare Advantage.