Enhanced claims review for claims over $50,000 beginning September 2026

Beginning September 1, 2026, the Itemized Bill Review (IBR) threshold will be lowered to $50,000.

What’s changing

Blue Cross NC will conduct an Itemized Bill Review for all facility claims with total charges over $50,000 submitted for Blue Cross NC members. Reviews will occur prepayment, consistent with our current process.

No delays in payment are anticipated as a result of this change. Claims meeting the IBR threshold will continue to follow normal turnaround times (TAT), provided all required documentation is complete and submitted timely.

Consistent with current processes, for all claims that meet this threshold, providers must submit the following at or before the time of claim submission:

• A complete Itemized Bill, and
• All applicable medical records

If a claim is submitted without all required documentation, it will be denied. The provider will receive notification of the denial via the Explanation of Payment (EOP) to indicate that additional information is required for review.

How to submit

Blue Cross NC accepts Itemized Bills and supporting medical records for electronically submitted claims through the methods outlined in our established submission guidance.

For detailed instructions on submitting Itemized Bills and medical records, refer to the official guidance on our website.

This requirement will apply to all Commercial, Medicare, and IPP Host lines of business. This will not apply to the Federal Employee Program.