Effective December 1: Medical Records Will Not Be Requested to Reprocess Medical Necessity Denials

Due to a recent clarification by the National Committee for Quality Assurance (NCQA), Blue Cross and Blue Shield of North Carolina (BCBSNC) must change its processes related to the ordering of medical records from providers when services and procedures supplied to its commercial members require additional documentation to determine medical necessity. NCQA has clarified that any determination around whether there is sufficient information to make a medical necessity determination is a medical necessity denial and must be denied by a medical director. Beginning with claims received on and after December 1, 2015, BCBSNC will no longer request medical records through our current processes, such as ProviderLink or by medical request letters, in order to reopen a denied claim when the medical records are received. Instead, the member and provider will receive a claim denial letter that will inform the member and provider of the specific reason(s) for the denial, provide reference to the criteria on which the denial decision was based, and advise the member and provider of their rights to appeal the decision. BCBSNC is currently evaluating new processes to allow medical records to be provided prior to a claim being denied for medical necessity reasons. Prior to December 1, 2015, BCBSNC will notify participating providers of available options for medical record submissions in advance of claims adjudication.