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Knowledge Center

Request prior review and authorization

Your health insurance provider may require your health care provider to submit a prior review and authorization before your plan will cover costs.

Prior review explained

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) must approve a prior review before your plan will help cover the cost of certain prescription medications, medical procedures, or health care services.

Other names for prior review include:

  • Prior approval
  • Prior authorization
  • Prospective review
  • Certification
  • Precertification

In an emergency, prior review isn't required. However, Blue Cross NC should be notified of an urgent or emergency admission by the second business day after the admission.

The purpose of prior reviews

Insurance companies use prior authorizations to help keep health care costs under control while making sure members get quality medical care.

Covered care

  • Your plan benefits cover the treatment or service.
  • Prescription drug coverage follows the guidelines of your formulary.

Medically necessary

  • The service is medically necessary (needed) according to Blue Cross NC medical policy.
  • If the service or treatment isn't medically necessary (elective), you may not be covered.

Approved location

  • The medically necessary service is performed in the right health care setting.
  • The performing provider is correctly identified as in- or out-of-network.

Quality care

  • Special medical circumstances are identified that require specific types of review and follow-ups.
  • Your health and wellness remain a top priority for care.

Note: Blue Cross NC may approve a service received out-of-network at the in-network benefit level:

  • If the service is not reasonably available in-network.
  • If there is a Continuity of Care issue, such as when the patient's provider used to be in-network but is now considered out-of-network.

What to expect during a prior review process

Your insurance provider will review all prior authorizations to decide if certain services, treatments, and prescription drugs are within the acceptable health care management guidelines of your plan. Typically, the prior review process includes several steps:

  • Your health care provider will submit the prior authorization to your health insurance company.
  • Your health insurance company will review the prior authorization and decide if it should be approved or denied.
  • Approved prior reviews are sent back to your provider. Your provider and / or your insurance company will let you know if it is approved.
  • Denied prior reviews are sent back to your provider with a reason for denial and information about how to submit an appeal to the insurance company.
  • You must get a prior review approved before the services, treatments, or prescription are provided.

Appealing denied prior reviews

Your insurance provider may deny the authorization if it believes the service, treatment, or prescription isn't medically necessary. However, you have the right to appeal a denied prior authorization, and your provider can submit an appeal to the insurance company.

Steps for providers

During the appeals process, your provider:

  • Does a peer-to-peer review with another doctor.
  • Sends additional information, showing why this course of treatment is medically necessary.

Steps for members

During the appeals process, you may need to:

  • Sign and send a member appeals form to your insurance company and give your provider permission to submit an appeal on your behalf.
Learn More About the Appeals Process

What may require prior review

Whether prior review and authorization is required may depend on your health insurance plan. For Blue Cross NC members, you can check your Benefit Booklet in your Blue Connect℠ member portal for specific information about your insurance plan.

Medical procedures:

  • Inpatient admissions (except maternity admissions), elective, planned in advance, or not related to an emergency
  • Inpatient maternity stays longer than 48 hours after vaginal delivery or 96 hours after a C-section
  • Private duty nursing, skilled nursing facility, acute rehabilitation admissions (short-term inpatient recovery), home health care (including nursing and some home infusion)
  • Services performed by an out-of-network or non-BlueCard® out-of-state health care provider
  • Air ambulance services (emergency air ambulance does not require prior review)
  • Certain durable medical equipment (DME)
  • Transplants, solid organ (for example, liver) or bone marrow / stem cell
  • Surgery and / or outpatient procedures

Prescription drugs:

  • Commercial prescription drugs, including treatments for attention-deficit / hyperactivity disorder (ADHD), Hepatitis C, biologics for arthritis and psoriasis, restricted-access medicines, and weight-loss drugs
  • Medicare prescription drugs
  • Medicare Part B Step Therapy and Prior Authorization drug list
  • Drugs with severe side effects
  • Drugs that potentially cause addiction
  • Drugs used for cosmetic purposes
  • Expensive drugs that have a lower-cost alternative

How to get a prior review

In-network providers

In-network providers can request a prior review and authorization by calling Blue Cross NC Utilization Management at 800-672-7897, Monday through Friday, 8 AM to 5 PM ET.

Prior Review Info for Providers

Out-of-network providers

Members are responsible for making sure out-of-network providers have requested prior review from Blue Cross NC before a service is performed.

This also applies to BlueCard® providers outside of North Carolina. These are out-of-state providers who contract with other Blue Cross Blue Shield plans.

Info for Providers to Become In-Network

Prior plan approval code list

This code list is informational only. It's a provider tool and is updated on a quarterly basis, within the first 10 days of January, April, July, and October. If there is no update within this time period, the list will remain unchanged until the next quarter.

View Service and Procedure (CPT) Codes