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Knowledge Center

Request prior review and authorization

We require prior review and authorization for certain services before they can be covered by your health insurance plan.

For in-network providers

North Carolina providers or specialists in the Blue Cross and Blue Shield of North Carolina (Blue Cross NC) network will request prior review for you. You may want to check with your health care provider to make sure that prior review and authorization was obtained before you have a service or procedure.

For out-of-network providers

You are responsible for making sure out-of-network doctors and providers have requested prior review and authorization 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).

Your Benefit Booklet has more information about prior review and authorization specific to your policy.

Prior review and authorization is also known as:

  • Prior approval
  • Prospective review
  • Certification
  • Precertification

In case of emergency, prior review and authorization is NOT required.

Blue Cross NC should be notified of an urgent or emergency admission by the second business day after the admission.

Prior review and authorization code list:

This list is provided for member information 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 following quarter.

View the Prior Plan Approval Code List.

Why is prior review and authorization necessary?

Prior review and certification ensures that:

  • Your benefits cover the service 
  • The service is medically necessary according to Blue Cross NC medical policy
  • The service is performed in the right health care setting
  • The provider is correctly identified as in- or out-of-network
  • Special medical circumstances are identified that require specific types of review and follow-up

Note: Blue Cross NC may authorize a service received out-of-network at the in-network benefit level if the service is not reasonably available in-network or if there is a continuity of care issue.

What types of procedures may require prior review and authorization?

Whether prior review and authorization is required may depend on your Blue Cross NC benefit plan. Always check your Benefit Booklet for specific information about your plan.

The following procedures typically require prior review and authorization:

  • 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

How can my provider request prior review and authorization?

Contact Blue Cross NC Utilization Management to request prior review and authorization by calling 800-672-7897, Monday through Friday, 8 a.m. to 5 p.m. ET.