BlueCrossNC.

com

PO Box 3866, Durham, NC 27702

Fraud, Waste, and Abuse Prepayment Review
Payment Integrity Office

FWA Prepayment Review Records Request

INSTRUCTIONS
IMPORTANT: This form will not be accepted for any type of appeal FOR PROVIDER USE ONLY – Fax Numbers and Mailing Address

 Submit one form for each claim or encounter If submitting records and documentation electronically, please use the
 All fields below are required following fax numbers:
 New or corrected claims should be submitted directly to the Blue Cross NC
claims department in accordance with the guidelines set forth in the Provider  Commercial: 844-264-5322
Blue Book (Including Federal Employee Program, Medicare Advantage,
 Due to current process limitations, submissions must be 300 pages or less or Medicare Supplemental)
 For submissions larger than 300 pages, please submit records via paper or  State Health Plan: 844-267-6886
contact the FWA prepayment review team to discuss alternatives (All documentation for the North Carolina State Health Plan
 Records and documentation received without the required information below for Teachers and State Employees)
will result in processing delays and may be returned
 Please send only copies of claims to the FWA prepayment team  IPP BlueCard: 844-347-8388
 New or corrected claims faxed to the FWA prepayment team for payment  IPP Host: 844-347-0903
consideration will not be accepted  Blue Cross NC Employee: 844-346-7271

PROVIDER INFORMATION If submitting records and documentation via paper, please send to the
following address:
PROVIDER NAME

Radeas LLC Blue Cross and Blue Shield of North Carolina

FWA Prepayment Review
PROVIDER MAILING ADDRESS P.O. Box 3866
907 Gateway Commons Circle, STE 100 Wake Forest NC 27587 Durham, NC 27702

CITY STATE ZIP CODE

Wake Forest NC 27587
INDIVIDUAL NPI NUMBER GROUP NPI NUMBER
1447592308 -
CLAIM INFORMATION
MEMBER NAME MEMBER DATE OF BIRTH
LADSON,HALAH 11/17/1978
MEMBER ID WITH ALPHA PREFIX AND TWO DIGIT SUFFIX DATE OF SERVICE Claim ID (If known)
Y2Y10515885200 8/4/2023 322805JNN0000

TYPE OF SUBMISSION
(You must check one of the following options)

Provide all records and documentation necessary to support all services billed on the claim under review as part of your submission

Proactive Claim Records - Proactive submission of supporting records and documentation in advance of a claim on prepayment review

X Adjudicated Claim Records - Submission of supporting records and documentation for a claim on prepayment review that has been previously adjudicated

Instructions for IDC and Document Operations Areas: Please process these records as document type SIU
 CLIA:34D2055932 907 Gateway Commons Circle, Wake Forest NC 27587 Ph: 919-263-1150 LD: P. T. Radford, PhD.

Patient Name Halah Ladson Patient ID BI2023-181 Patient DOB 11/17/1978

Doctor (Provider) Mary Urban Specimen ID PJCHPEEG-1017 Sample Type Urine
Acquisition Date 08/04/2023 Clinic ID 2360A TBI NC Lab Tech/RD/MI NAT/SWR 230808 FGI
pH 5 Specific Gravity ≥1.030 Creatinine (mg/dL) 200

Medication List Medication Comparison Summary

Bupropion, Lorazepam, Inconsist. – Not Prescribed Inconsistent – RX Not Found Consistent
Clonazepam, Gaba., Trazodone EtG, EtS Clonazepam, Lorazepam, Gabapentin, Trazodone Bupropion

Cutoff POS
Drug Class Scrn Test Performed Drug Brand Result C/I Flag
(ng/ml) NEG
Codeine Fioricet w/codeine. Tyl. 3 & 4 ND 50 NEG C
Opiates
- Morphine Avinza, Kadian, MScontin ND 50 NEG C
Hydromorphone Dilaudid, Exalgo, Palladone ND 50 NEG C
Vicodin, Norco, Lortab,
- Hydrocodone Vicoprofen ND 50 NEG C
Norhydrocodone Metab. of Hydrocodone ND 50 NEG C
Dextromethorphan Delsym ND 100 NEG C
Opioids and
Levorphanol Levo-Dromoran ND 100 NEG C
Opiate Analogs
Normeperidine Metab. of Meperidine ND 50 NEG C
Naloxone Narcan ND 100 NEG C
Naloxone Metab. Metab. of Naloxone ND 100 NEG C
Naltrexone Revia, Vivitrol, Embeda ND 30 NEG C
Oxycontin, Percocet,
- Oxycodone Roxicodone ND 50 NEG C
Oxycodone Noroxycodone Metab. of Oxycodone ND 50 NEG C
Oxymorphone Opana, Numorphan ND 50 NEG C
Suboxone, Butrans, Subutex,
Buprenorphine Buprenex ND 30 NEG C
Buprenorph. Metab. Metab. of Buprenorphine ND 30 NEG C
Buprenorphine
Norbuprenorphine Metab. of Buprenorphine ND 30 NEG C
Norbuprenor. Metab. Metab. of Buprenorphine ND 30 NEG C
Duragesic, Actiq, Fentora,
Fentanyl Ionsys ND 3 NEG C
Fentanyl
Norfentanyl Metab. of Fentanyl ND 3 NEG C
- Methadone Methadose, Dolophine ND 100 NEG C
Methadone
EDDP Metab. of Methadone ND 100 NEG C
Barbiturates - Barbiturates Butablbital, Phenbobarbital NA 300 NEG C
Alkaloids Cotinine Metab. of Nicotine ND 50 NEG C
(not otherwise specified) LSD-25 LSD, Acid, Lysergide ND 50 NEG C
Tapentadol Tapentadol Nucynta ND 50 NEG C
Ultram, ConZip, Ryzolt,
Tramadol Tramadol Ultracet ND 100 NEG C
- Alprazolam Xanax, Niravam ND 100 NEG C
A-hydroxyalprazolam Metab. of Alprazolam ND 30 NEG C
Metab. of Clonazepam
Clonazepam (7-Amino)* (Klonopin) ND 50 NEG I Indicated med not detected
Benzodiazepines Nordiazepam Metab. of Diazepam ND 40 NEG C
- Temazepam Restoril ND 40 NEG C
Oxazepam Serax ND 50 NEG C
Lorazepam* Ativan ND 40 NEG I Indicated med not detected
Sedatives/Hypnotics Zolpidem Ambien ND 50 NEG C
Skeletal Muscle Carisoprodol Soma, Vanadom ND 100 NEG C
Equanil, Miltown, MB-TAB,
Relaxants Meprobamate Equagesic, ND 50 NEG C
Elavil, Laroxyl, Saroten,
Amitriptyline Sarotex ND 50 NEG C
Sonsoval, Aventyl, Pamelor,
Antidepressants Nortriptyline Norpress, Allegon, Noritren ND 50 NEG C
(TCAs)
Cyclobenzaprine Flexeril ND 50 NEG C
Doxepin Deptran, Sinequan, Prudoxin ND 50 NEG C
Citalopram Celexa, Cipramil ND 50 NEG C
Antidepressants Duloxetine Cymbalta ND 50 NEG C
Paxil, Pexeva, Brisdelle,
(Serotonergic class) Paroxetine Rexetin ND 50 NEG C
Sertraline Zoloft, Lustral ND 50 NEG C
Hydroxybupropion* Metab. of Bupropion 1080 50 POS C
Remeron, Avanza, Axit,
Antidepressants Mirtazapine Mirtazon, Zispi ND 50 NEG C
(not otherwise specified) Venlafaxine Efexor, Effexor, Trevilor ND 50 NEG C
O-desmethylven. Pristiq ND 50 NEG C
Aripiprazole Abilify ND 50 NEG C
Antipsychotics Haloperidol Haldol ND 50 NEG C
(not otherwise specified) Quetiapine Seroquel ND 50 NEG C
Desyrel, Mesyrel, Oleptro,
Trazodone* Trazorel ND 50 NEG I Indicated med not detected
Antiepileptics Lamotrigine Lamictal ND 50 NEG C
(not otherwise specified)

Gabapentin Gabapentin* Neurontin, Gralise, Horizant ND 50 NEG I Indicated med not detected
 CLIA:34D2055932 907 Gateway Commons Circle, Wake Forest NC 27587 Ph: 919-263-1150 LD: P. T. Radford, PhD.

Pregabalin Pregabalin Lyrica ND 50 NEG C

Concerta, Methylin, Ritalin,
Methylphenidate Methylphenidate Equasym XL ND 50 NEG C
Ketamines Ketamine An aneaesthetic ND 50 NEG C
Mitragynine Mitragynine Kratom, Biak Biak ND 50 NEG C
- Amphetamine Adderall, Vyvanse ND 50 NEG C
Amphetamines Methamphetamine Crystal Meth ND 100 NEG C
Phentermine Suprenza, Adipex-P ND 50 NEG C
Heroin Metabolite 6-MAM Metab of Heroin ND 30 NEG C
Cocaine - Benzoylecgonine Metab. of Cocaine ND 50 NEG C
Methylenedioxy- MDA 3,4 MD Amph., Club Drug ND 100 NEG C
amphetamines MDMA Ecstasy ND 100 NEG C
Stimulants (Synthetic) MDPV Bath Salts ND 100 NEG C
Phencyclidine PCP Phencyclidine ND 30 NEG C
Cannabinoids (Natural) Carboxy-THC Metab. of Marijuana ND 30 NEG C
Cannabinoids (Synthetic) JWH-018 Synthetic Marijuana ND 30 NEG C
Ethyl glucuronide Metab. of Ethanol 8620 500 POS I Non-indicated subst. detected
Alcohol(s)
Ethyl sulfate Metab. of Ethanol 2690 500 POS I Non-indicated subst. detected
ND- Not Detected. NEG (-) - Drug below cutoff level. POS (+) - Drug above cutoff level. Consistent (C)- Prescribed drug detected at any level or unprescribed / illicit drug below cutoff level. Inconsistent (I)-
Prescribed drug not detected at any level or unprescribed / illicit drug above cutoff level. * Prescribed medication. Detection windows are typically 3-5 days. Higher doses and certain pathologies may extend the
detection window. Scr. indicates the presumptive screen with a cutoff of 100ng/ml. Metab. – Metabolite. Hydrolysis not performed, free drug measured. The performance specifications for the test were established by the
testing laboratory and the test methodology has not been cleared or approved by the FDA. This report is for preliminary screening and definitive confirmation testing.

Specific gravity ≥1.030

Rerun Confirmed