--- title: Practice Support Services | insurance description: insurance | Health care practices in North Carolina face many challenges. Our quality improvement coaches (QICs) are trained to work with you to transform the way in which care is delivered in your practice. --- [![nwahec.png](https://go.northwestahec.wakehealth.edu/hs-fs/hubfs/WFUSM_NWAHEC%20Cobranding%20Logo_H_RGB.png?width=2025&height=300&name=WFUSM_NWAHEC%20Cobranding%20Logo_H_RGB.png "nwahec.png")](https://go.northwestahec.wakehealth.edu/) - [Home](https://go.northwestahec.wakehealth.edu) - [What's New at NWAHEC Blog](https://go.northwestahec.wakehealth.edu/blog) - [NWAHEC Staff](https://go.northwestahec.wakehealth.edu/staff) - [Practice Support Updates](https://go.northwestahec.wakehealth.edu/practicesupport) # Practice Support Update Blog ## [Payers in NC Implement Downcoding Claims and Code Review Programs](https://go.northwestahec.wakehealth.edu/practicesupport/payers-in-nc-implement-downcoding-claims-and-code-review-programs) Sep 2, 2025, 9:30:00 AM / by [Practice Support Team](https://go.northwestahec.wakehealth.edu/practicesupport/author/practice-support-team) posted in [coding](https://go.northwestahec.wakehealth.edu/practicesupport/topic/coding), [practice management](https://go.northwestahec.wakehealth.edu/practicesupport/topic/practice-management), [claims](https://go.northwestahec.wakehealth.edu/practicesupport/topic/claims), [insurance](https://go.northwestahec.wakehealth.edu/practicesupport/topic/insurance) [0 Comments](https://go.northwestahec.wakehealth.edu/practicesupport/payers-in-nc-implement-downcoding-claims-and-code-review-programs#comments-listing) ![Strong Connection between Chrome Carabiner and two Red Ropes Symbolising the Insurance. Selective Focus.-1](https://go.northwestahec.wakehealth.edu/hs-fs/hubfs/Strong%20Connection%20between%20Chrome%20Carabiner%20and%20two%20Red%20Ropes%20Symbolising%20the%20Insurance.%20Selective%20Focus.-1.jpeg?width=300&height=180&name=Strong%20Connection%20between%20Chrome%20Carabiner%20and%20two%20Red%20Ropes%20Symbolising%20the%20Insurance.%20Selective%20Focus.-1.jpeg) Several health insurance companies in North Carolina have recently implemented programs to review claims and codes that results in the down coding of Level 4 and Level 5 Evaluation and Management (E/M) claims. According to the [North Carolina Medical Society](https://ncmedsoc.org/latest-update-on-nc-health-insurance-payers-implementing-downcoding-claims-review-programs/), Aetna's process does not target all Level 4 and 5 codes, nor does it include all providers within the state. However, there remains confusion about why the insurer has implemented this program. [Cigna's approach is broader](https://providernewsroom.com/cigna-healthcare/new-reimbursement-policy-for-professional-evaluation-and-management-services-claims-effective-october-1-2025/) and applies to all physicians and to six E/M codes: 99204-99205 (new patient), 99214-99215 (established patient), and 99244-99245 (consult for new & established patients). Cigna will implement this review nationally on October 1, 2025.   Along with the North Carolina Medical Society, many [professional societies](https://www.apma.org/about-apma/news/news-releases/2025/apma-takes-action-engaging-aetna-on-downcoding-policy/) across the country are also [alerting their members](https://www.texmed.org/TexasMedicineDetail.aspx?id=66499) to this issue.  It is critical to follow the appropriate appeals process for any claims you believe to be inappropriately down coded!  [Read More](https://go.northwestahec.wakehealth.edu/practicesupport/payers-in-nc-implement-downcoding-claims-and-code-review-programs) ## [Reminder: Aetna North Carolina State Employees Health Plan launches Jan 1, 2025](https://go.northwestahec.wakehealth.edu/practicesupport/north-carolina-state-employees-health-plan-0) Dec 19, 2024, 7:45:00 AM / by [Practice Support Team](https://go.northwestahec.wakehealth.edu/practicesupport/author/practice-support-team) posted in [practice management](https://go.northwestahec.wakehealth.edu/practicesupport/topic/practice-management), [insurance](https://go.northwestahec.wakehealth.edu/practicesupport/topic/insurance), [state health plan](https://go.northwestahec.wakehealth.edu/practicesupport/topic/state-health-plan) [0 Comments](https://go.northwestahec.wakehealth.edu/practicesupport/north-carolina-state-employees-health-plan-0#comments-listing) ![USA\_North\_Carolina\_relief\_map\_cut.wikimedia commons](https://go.northwestahec.wakehealth.edu/hs-fs/hubfs/USA_North_Carolina_relief_map_cut.wikimedia%20commons.png?width=300&height=121&name=USA_North_Carolina_relief_map_cut.wikimedia%20commons.png)   If your organization participates in the Aetna State Plan, we advise you to confirm your participation ahead of the January 1, 2025 launch date! Effective January 1, 2025, Aetna will replace Blue Cross Blue Shield NC for the NC State Health Plan coverage. Which plans are included? - Enhanced PPO Plan (80/20) - Basic PPO Plan (70/30) - High Deductible Health Plan (HDHP) This change does NOT impact members enrolled in the Humana Medicare Advantage plans. The current pharmacy benefit manager (CVS Caremark®) will not change. [Read More](https://go.northwestahec.wakehealth.edu/practicesupport/north-carolina-state-employees-health-plan-0) ## [North Carolina State Employees Health Plan](https://go.northwestahec.wakehealth.edu/practicesupport/north-carolina-state-employees-health-plan) Nov 19, 2024, 2:15:00 PM / by [Practice Support Team](https://go.northwestahec.wakehealth.edu/practicesupport/author/practice-support-team) posted in [practice management](https://go.northwestahec.wakehealth.edu/practicesupport/topic/practice-management), [insurance](https://go.northwestahec.wakehealth.edu/practicesupport/topic/insurance), [state health plan](https://go.northwestahec.wakehealth.edu/practicesupport/topic/state-health-plan) [0 Comments](https://go.northwestahec.wakehealth.edu/practicesupport/north-carolina-state-employees-health-plan#comments-listing) ![USA\_North\_Carolina\_relief\_map\_cut.wikimedia commons](https://go.northwestahec.wakehealth.edu/hs-fs/hubfs/USA_North_Carolina_relief_map_cut.wikimedia%20commons.png?width=300&height=121&name=USA_North_Carolina_relief_map_cut.wikimedia%20commons.png) Effective January 1, 2025, Aetna will replace Blue Cross Blue Shield NC for the NC State Health Plan coverage. Which plans are included? - Enhanced PPO Plan (80/20) - Basic PPO Plan (70/30) - High Deductible Health Plan (HDHP) This change does NOT impact members enrolled in the Humana Medicare Advantage plans. The current pharmacy benefit manager (CVS Caremark®) will not change. [Read More](https://go.northwestahec.wakehealth.edu/practicesupport/north-carolina-state-employees-health-plan) ## [You're invited! Learn about Aetna's involvement with the State Health Plan and the Clear Pricing Project](https://go.northwestahec.wakehealth.edu/practicesupport/youre-invited-learn-about-aetnas-involvement-with-the-state-health-plan-and-the-clear-pricing-project) Nov 1, 2023, 5:30:00 PM / by [Practice Support Team](https://go.northwestahec.wakehealth.edu/practicesupport/author/practice-support-team) posted in [practice management](https://go.northwestahec.wakehealth.edu/practicesupport/topic/practice-management), [insurance](https://go.northwestahec.wakehealth.edu/practicesupport/topic/insurance), [state health plan](https://go.northwestahec.wakehealth.edu/practicesupport/topic/state-health-plan) [0 Comments](https://go.northwestahec.wakehealth.edu/practicesupport/youre-invited-learn-about-aetnas-involvement-with-the-state-health-plan-and-the-clear-pricing-project#comments-listing)   [Read More](https://go.northwestahec.wakehealth.edu/practicesupport/youre-invited-learn-about-aetnas-involvement-with-the-state-health-plan-and-the-clear-pricing-project) [All posts](https://go.northwestahec.wakehealth.edu/practicesupport/all) This is a search field with an auto-suggest feature attached. - There are no suggestions because the search field is empty. ### Practice Support Services Health care practices in North Carolina face many challenges. Our team of quality improvement coaches (QICs) have skills and expertise to support you in your transformation efforts. To learn more about [Practice Support Click Here](https://school.wakehealth.edu/Education-and-Training/Continuing-Professional-Education/Northwest-AHEC/Practice-Support-Services) Apply for practice support services - **[submit an email inquiry](mailto:practicesupport@ncahec.net)** ### Subscribe to Blog Updates ### Additional Resources: [![Tip Sheets](https://no-cache.hubspot.com/cta/default/7413846/3250b519-7b04-46c8-8a05-c761461c996f.png)](https://cta-redirect.hubspot.com/cta/redirect/7413846/3250b519-7b04-46c8-8a05-c761461c996f) [![Lib Guides](https://no-cache.hubspot.com/cta/default/7413846/a0754bf6-f1f0-475d-bbf4-17bea63ef9c1.png)](https://cta-redirect.hubspot.com/cta/redirect/7413846/a0754bf6-f1f0-475d-bbf4-17bea63ef9c1) [![Interactive Resource Guides](https://no-cache.hubspot.com/cta/default/7413846/84d3d6ee-36ec-4b91-9ec2-410c87e1fefc.png)](https://cta-redirect.hubspot.com/cta/redirect/7413846/84d3d6ee-36ec-4b91-9ec2-410c87e1fefc) [![Digital Library](https://no-cache.hubspot.com/cta/default/7413846/36614b2e-461f-444c-b2a9-08ee8a5f03c1.png)](https://cta-redirect.hubspot.com/cta/redirect/7413846/36614b2e-461f-444c-b2a9-08ee8a5f03c1) [![Join email list](https://no-cache.hubspot.com/cta/default/7413846/d2ffefd9-3e10-48ff-95be-d9cd6d269bd2.png)](https://cta-redirect.hubspot.com/cta/redirect/7413846/d2ffefd9-3e10-48ff-95be-d9cd6d269bd2) Connect With Us: ### Posts by Topic - 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Check Out These Recent Posts # About Us The Northwest Area Health Education Center of Wake Forest University School of Medicine provides and supports educational activities and services with a focus on primary care in rural communities and those with less access to resources to recruit, train and retain the workforce needed to create a healthy North Carolina. 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