Understanding how claims are priced and adjudicated

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 services provided to both commercial and Medicare Advantage members. Please review the following policies:

• Pricing and Adjudication Principles – Commercial Reimbursement Policy
• Pricing and Adjudication Principles – Medicare Reimbursement Policy

To support accurate claims submission, Blue Cross NC applies industry‑standard coding, billing, and editing guidelines to all claims. Understanding how these guidelines are used during claims review can help reduce avoidable denials and post‑payment adjustments.

Please note that prior approval for procedures or services does not guarantee reimbursement. All claims remain subject to applicable coding, billing, and editing guidelines at the time of processing.

Providers are encouraged to review these policies in detail to ensure compliance and avoid unnecessary administrative burden.