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BCBS NC update Medicare Advantage Plans reimbursement (pricing policy), 04/01/2021

Currently, BCBS of North Carolina uses 2 vendor-based solutions for Medicare Advantage claims pricing:  

  1. The Optum Pricing Module is used for facility claims and certain other module pricing (ex. Home Health, ESRD, etc.) This pricing module is integrated with Blue Cross NC claims processing system.  
  2. The Burgess pricing solution is used for professional claims. This pricing model is not integrated with Blue Cross NC claims processing system. 

In order to reduce administrative complexity of managing a separate vendor and contract, as well as align with more frequent CMS pricing updates and industry standards, BCBSNC will retire Burgess Pricing module and utilize Optum Pricing Module for both facility and professional claims.

Out-of-network providers will be affected by this change in Q1 2021. Participating providers will be subject to this new pricing policy in Q2 2021.

If you have any questions, please contact BCBSNC via phone: 1-800-777-1643Option #6

Or email:

#BCBSNC #MedicareAdvantage #Optum #outofnetwork #pricing #reimbursement



My name is Kate Patskovska, CPB. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. KR2 Medical Billing is a full service Consulting/Medical Billing Business that is dedicated to educating, consulting, and overall improving the "financial health" of your medical practice.

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