Medicare Advantage Peer-to-Peer Process Change Effective January 1, 2027

Effective January 1, 2027, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will no longer proactively initiate peer-to-peer discussions before issuing an adverse determination for Medicare Advantage and Dual Eligible Special Needs Plan (D-SNP) prior authorization requests. Providers may continue to contact our clinical team during the review process to discuss a case or provide additional clinical information.

To support timely and accurate determinations, providers should submit complete clinical documentation with the initial request, including all information needed to demonstrate medical necessity under the applicable coverage and clinical criteria.

Blue Cross NC will continue to review all clinical information submitted during the review process and issue determinations within applicable Medicare required timeframes.

If a provider or member disagrees with the determination, the appeal rights described in the determination notice remain available. Providers should continue to use standard provider support channels for questions about authorization documentation or submission requirements.