Update on Evaluation and Management Related Services Recoupment

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) recently updated the 50% reimbursement of Problem Oriented Evaluation and Management Related Services when submitted on the same date as Preventive Medicine or Annual Wellness encounter, to effective date September 8, 2022.   

On August 16, 2022 we posted an Update on Evaluation and Management Related Services informing providers of a technical issue where our editing was not properly adjudicating the problem visit at the 50% allowance, according to the policy for claims with dates of service June 1, 2021 to May 31, 2022.   

Additionally, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) recently identified a separate technical issue that prevented most E&M claims filed between June 1, 2022 and September 7, 2022, from being processed in accordance with the updated E&M commercial reimbursement policy.

As a result, claims submitted for dates of service between June 1, 2021 and September 7, 2022, will not be subject to the updated E&M commercial reimbursement policy (PDF) due to this technical error. Claims submitted for dates of service September 8, 2022 and beyond will process in alignment with the updated policy.

If you have received a request for recoupment, please disregard at this time. If you have submitted a refund in response to our request, more details will be shared soon on the process for reversing your payment.

We apologize for the confusion, and we’re working as quickly as possible to make things right. We appreciate your ongoing patience as we continue our work to resolve this. If you have questions or need assistance, please contact Customer Service at the number listed on your invoice.

This communication applies to the following lines of business: Administrative Services Only (ASO), fully insured membership, IPP Host, and the State Health Plan (SHP).