Reimbursement policy reminder: Pricing and adjudication principles related to denied or non-covered procedures or services

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) would like to remind our provider community of our Pricing and Adjudication Principles reimbursement policies for both commercial and Medicare, established in August 2022.

Under these policies, associated services – both professional and facility – related to denied procedures are considered non-covered and are not reimbursable. The following are reasons for denials:

• Services determined to be not medically necessary
• Procedures considered investigational or experimental or cosmetic
• Services rendered without required prior plan approval or a denied prior plan approval

Claims reprocessed under this post-pay edit will include specific denial codes that indicate associated services are also denied. Providers will see the following Explanation of Payment (EOP) / Explanation of Benefits (EOB) messages when these claims are adjusted via post pay recoupment.

• Associated Services are denied due to the primary service denial. Do not bill patient, provider liability.

We are sharing these reminders due to ongoing issues with claim identification and to help our providers avoid future recoupments. Providers are encouraged to review these policies in detail to ensure compliance and avoid unnecessary administrative burden.