Update: Implementation of Lesser of Logic for UB04 Medicare claims

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) published a communication on May 29, 2026, regarding the implementation of Lesser of Logic for UB04 Medicare Advantage (MA) claims. This notice provides additional clarification and information.

Lesser of Logic will continue to be implemented on a UB04 claim for MA providers. The following provider types will not have Lesser of Logic applied:

• Hospital IP DRG
• Hospital - OP
• Hospital - IPF (Inpatient Psychiatric Facilities)-Per Diem, DRG
• Hospital - IRF (Inpatient Rehabilitation Facilities)- Per Diem, PPS (CMG)
• Critical Access Hospital - Per Diem (IP)
• Hospital - LTCH (Long Term Care Hospitals) (IP/APC)
• Rural Health Clinics - Per Diem (IP/APC)
• Organ Acquisition Hospital Inpatient DRG (Add on Cost)

Providers should carefully review their billed charges to ensure accuracy and alignment with contractual expectations.

Providers may contact their contract representative with any questions.