Blue Cross and Blue Shield of North Carolina (Blue Cross NC) reviews certain behavioral health, medical services, equipment, and medications against health care management guidelines prior to the services being provided.1
We may require prior authorization reviews to confirm:
- Member eligibility
- Benefit coverage
- Compliance with Commercial and Blue Medicare℠ medical policies regarding medical necessity
- Appropriateness of setting
- Requirements for use of in-network and out-of-network facilities and professionals
- Identification of comorbidities and other problems requiring specific discharge needs
- Identification of circumstances that may indicate:
- a referral to concurrent review, discharge services, or case management
- a referral to a second opinion, continuity of care, or case management
- a referral to chronic case management
- Services on the Prior Authorization Code List that are rendered emergently or urgently during an inpatient admission are still subject to medical necessity criteria.
Use our search tools to determine if we need prior authorization and how to submit authorization requests.
Search for services and durable medical equipment for plans requiring prior authorization.
Search for prescription drugs for plans requiring prior authorization.
Medical policies, medical necessity criteria, and medical record submission requirements play a part in informing our prior authorization decisions. Review these policies and what you may need to submit with prior authorization requests.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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