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, 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 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 across the country are also alerting their members to this issue. 

It is critical to follow the appropriate appeals process for any claims you believe to be inappropriately down coded! 

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.

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.