New E&M Leveling program and updated E&M Reimbursement Policy

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is committed to accurate and consistent coding and reimbursement. As part of this commitment, Blue Cross NC is taking additional steps to assess claims for office or other outpatient evaluation and management (E&M) services submitted by professional providers.

Beginning August 15, 2026, Blue Cross NC will institute the Office and Other Outpatient E&M Leveling program, where select practitioners will be identified for inclusion who have a consistent pattern of coding at a higher E&M level compared to their peers.

Blue Cross NC will use an analytic solution supported by human and clinical review to determine whether E&M services submitted by the identified providers are aligned with national industry coding standards. If the billed E&M service is higher than is supported by all services and/or conditions submitted, the E&M service may be subject to denial or reimbursed based on the appropriate level. The standard dispute process is available for practitioners who wish to request a review. See the related Commercial policy notification and Medicare policy notification for more information.

The updated reimbursement policy will not automatically result in an adjustment of reimbursement for all claims. The policy only applies to providers identified to participate in the program. Providers entering this program will receive advance notice of program inclusion. If a letter is not received, no further action is needed.

This policy applies to Commercial and Medicare Advantage. This does not apply to Federal Employee Program (FEP), Inter-Plan Program (IPP) Host or IPP Home.