Blue Cross and Blue Shield of NC claim denials in North Carolina: the federal figures
Blue Cross and Blue Shield of NC denied 18.9% of in-network claims in North Carolina — 3,337,685 claims out of 17,691,687. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to Blue Cross and Blue Shield of NC) | 1,372 | 34.6% |
| External review (independent) | 47 | 53.2% |
What Blue Cross and Blue Shield of NC denies most
The most common denial reason recorded for Blue Cross and Blue Shield of NC plans in North Carolina is other reasons. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Other reasons | 1,088,291 | 52.8% |
| Service excluded from the plan | 304,074 | 14.7% |
| Member not covered | 302,754 | 14.7% |
| Administrative reason | 189,924 | 9.2% |
| Referral required | 89,453 | 4.3% |
| Benefit limit reached | 64,792 | 3.1% |
| Provider out of network | 19,784 | 1% |
| Not medically necessary | 2,345 | 0.1% |
| Experimental or investigational | 800 | 0% |
What to do if Blue Cross and Blue Shield of NC denied your claim
- Get the reason in writing. The denial notice must state the specific reason and the plan provision behind it. If it does not, request it — you are entitled to it free of charge.
- File the internal appeal. Generally within 180 days of the denial notice. Blue Cross and Blue Shield of NC overturned 34.6% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not Blue Cross and Blue Shield of NC. Generally you have 4 months from the final internal denial. This is the step nearly everyone skips.
- Ask for expedited review if waiting would seriously jeopardise your health. That timeline is days, not months.
Everything you need for your Blue Cross and Blue Shield of NC appeal: your two deadlines, the argument that fits your denial reason, an evidence checklist, and the external review request. Opens on screen the moment you pay.
Questions
Is Blue Cross and Blue Shield of NC's denial rate high?
18.9% against a national average of 16% across the plans in this dataset. It is above average. A denial rate describes the insurer, not the merits of your claim.
Does appealing cost anything?
The internal appeal is free. External review is free under the HHS-administered federal process; where an issuer uses a contracted independent review organization or a state process, any fee is capped at $25.
Can Blue Cross and Blue Shield of NC ignore the external decision?
No. External review decisions are binding on the plan.